Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10287
Peer-review started: August 2, 2016
First decision: September 28, 2016
Revised: October 16, 2016
Accepted: November 28, 2016
Article in press: November 28, 2016
Published online: December 21, 2016
Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon’s assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot’s triangle clearance in the overhead view; (5) Calot’s triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot’s triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.
Core tip: In 1995, the concept of the critical view of safety was clearly established. In 2006, it was revolutionarily suggested that a high level of experience alone is not sufficient for successful laparoscopic cholecystectomy (LC). In 2016, we described a protocol for successful LC, even in patients with inflammatory changes and rare anatomies. Thus, the mandatory protocol for LC seems to have undergone stepwise development in every decade. Although all surgeons are at risk of making errors based on their own assumptions during LC, we believe that adherence to the herein-described protocol preserves the benefits of LC for patients worldwide.