Abstract
Background
The critical view of safety (CVS) is the gold standard for performing safe cholecystectomies and minimizing common bile duct (CBD) injuries. It requires three criteria: complete clearance of the hepatocystic triangle, partial separation of the gallbladder from the cystic plate, and two structures alone entering the gallbladder. However, biliary anatomy varies widely, with frequent aberrant arterial supplies, which can mislead or disorient those attempting to acquire the CVS. This study was designed to examine the nature and frequency of cystic artery anatomic anomalies.
Methods
We conducted a prospective observational study from 2018 to 2020, compiling photos of the critical view of safety of 100 consecutive elective cholecystectomies performed at our institution. Gallbladders were dissected up to the parallel portion of the cystic plate to achieve a critical view of safety. All tubular structures were preserved and clipped. Operative reports were examined for mention of posterior cystic arteries or aberrant arterial supplies. Photos were reviewed for an adequate critical view of the safety and presence of aberrant arterial supplies. The rate of aberrant arterial supply was determined and photos were reviewed for patterns of common abnormalities.
Results
There were 121 patients who underwent an elective cholecystectomy; 21 lacked intraoperative pictures and were excluded from the study. Of the 100 patients included, 57 (57%) had an aberrant arterial supply with more than one cystic artery; seven had three concurrent arteries. Of those with more than one cystic artery, 21% had a recurrent cystic artery, 21% had a posterior dominant cystic artery, and 12% had a low-branching anterior cystic artery.
Conclusion
Even with appropriate dissection for the CVS, surgeons can expect to frequently visualize more than two structures entering the gallbladder when a posterior cystic artery is present. It is, therefore, integral to distinguish this aberrant anatomy to prevent inadvertent injury to the CBD.
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References
Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. Journal of Gastrointestinal Surgery. 2009;13(3):498-503.
Connor SJ, Perry W, Nathanson L, Hugh TB, Hugh TJ. Using a standardized method for laparoscopic cholecystectomy to create a concept operation-specific checklist. HPB. 2014;16(5):422-429.
Ding Y-M, Wang B, Wang W-X, Wang P, Yan J-S. New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy. World journal of gastroenterology: WJG. 2007;13(42):5629.
Pucher PH, Brunt LM, Fanelli RD, Asbun HJ, Aggarwal R. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surgical endoscopy. 2015;29(11):3074-3085.
Michael Brunt L, Deziel DJ, Telem DA, et al. Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surgical Endoscopy. 2020;34(7):2827-2855.
Barrett M, Asbun HJ, Chien H-L, Brunt LM, Telem DA. Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surgical endoscopy. 2018;32(4):1683-1688.
Fong ZV, Pitt HA, Strasberg SM, et al. Diminished survival in patients with bile leak and ductal injury: management strategy and outcomes. Journal of the American College of Surgeons. 2018;226(4):568-576. e561.
Strasberg SM, Eagon CJ, Drebin JA. The “hidden cystic duct” syndrome and the infundibular technique of laparoscopic cholecystectomy—the danger of the false infundibulum. Journal of the American College of Surgeons. 2000;191(6):661-667.
Andall R, Matusz P, Du Plessis M, Ward R, Tubbs R, Loukas M. The clinical anatomy of cystic artery variations: a review of over 9800 cases. Surgical and Radiologic Anatomy. 2016;38(5):529-539.
Wang X, Shah RP, Maybody M, et al. Cystic artery localization with a three-dimensional angiography vessel tracking system compared with conventional two-dimensional angiography. Journal of Vascular and Interventional Radiology. 2011;22(10):1414-1419.
Suzuki M, Akaishi S, Rikiyama T, Naitoh T, Rahman M, Matsuno S. Laparoscopic cholecystectomy, Calot's triangle, and variations in cystic arterial supply. Surgical endoscopy. 2000;14(2):141-144.
Sugita R, Yamazaki T, Fujita N, Naitoh T, Kobari M, Takahashi S. Cystic artery and cystic duct assessment with 64–detector row CT before laparoscopic cholecystectomy. Radiology. 2008;248(1):124-131.
Fathy O, Zeid MA, Abdallah T, et al. Laparoscopic cholecystectomy: a report on 2000 cases. Hepato-gastroenterology. 2003;50(52):967-971.
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Ostapenko, A., Kleiner, D. Challenging Orthodoxy: beyond the Critical View of Safety. J Gastrointest Surg 27, 89–92 (2023). https://doi.org/10.1007/s11605-022-05500-z
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DOI: https://doi.org/10.1007/s11605-022-05500-z