Journal
JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES
Volume 26, Issue 4, Pages 123-127Publisher
WILEY
DOI: 10.1002/jhbp.616
Keywords
Acute cholecystitis; Bile duct injury; Biliary colic; Biliary injury; Cholecystectomy; Critical view of safety; Inflection point; Laparoscopic cholecystectomy; Subtotal cholecystectomy; Subtotal fenestrating cholecystectomy; Subtotal reconstituting cholecystectomy
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Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification - the inflection point; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy - and instead to bail-out. This inflection point is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.
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