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The critical view of safety in laparoscopic cholecystectomy is optimized by

exposing the inner layer of the subserosal layer

Article  in  Journal of Hepato-Biliary-Pancreatic Surgery · April 2009

DOI: 10.1007/s00534-009-0060-3 · Source: PubMed

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J Hepatobiliary Pancreat Surg (2009) 16:445–449
DOI 10.1007/s00534-009-0060-3

SURGEON AT WORK

The critical view of safety in laparoscopic cholecystectomy

is optimized by exposing the inner layer of the subserosal layer
Goro Honda Æ Tomohiro Iwanaga Æ Masanao Kurata Æ
Fumiaki Watanabe Æ Hiroki Satoh Æ Ken-ichi Iwasaki

Received: 18 October 2008 / Accepted: 9 November 2008 / Published online: 4 March 2009
Ó Springer 2009

Abstract During laparoscopic cholecystectomy (LC), Introduction

misidentification of the cystic duct, which causes major
bile duct injuries, can result from wrong or incomplete During laparoscopic cholecystectomy (LC), misidentifi-
dissection of Calot’s triangle. Therefore, the critical view cation of the cystic duct, which causes major bile duct
of safety has been accepted as a safe method for gaining a injuries, can result from wrong or incomplete dissection of
sufficient view of Calot’s triangle before transecting the Calot’s triangle [1, 2]. Recently, the critical view of safety
cystic duct. However, even in cases without aberrant has been accepted as a safe method for gaining a sufficient
anatomy of the bile duct, bile duct injury can occur by a view of Calot’s triangle before transecting the cystic duct
wrong approach to a critical view of safety. Additionally, [2, 3]. However, even in cases without aberrant anatomy of
in cases of badly inflamed gallbladders, it is often hard to the bile duct, bile duct injury can occur by the wrong
achieve a critical view of safety, because Calot’s triangle is approach to the critical view of safety. Additionally, in
often solid and cannot be expanded. In our standardized cases of badly inflamed gallbladders, it is often hard to
procedure, which is based on exposing the inner layer of achieve a critical view of safety, because Calot’s triangle is
the subserosal layer (the ss-i layer), the critical view of often solid and cannot be expanded.
safety can be safely achieved. We have safely performed In such situations, to define the standard procedure for
LC, using our standardized procedure, for many cases with LC, we confirmed, by making parallel comparisons
cholecystitis with highly inflamed gallbladders. In this between clinical video and histological findings, anatomi-
article, focusing especially on prevention of bile duct cal structures that can be used as landmarks in the surgical
injuries, we present our standardized procedure to achieve field. We determined that exposing the inner layer of the
the critical view of safety along with histological findings. subserosal (ss) layer optimizes the critical view of safety.
Based on that, we developed our standardized procedure,
Keywords Critical view of safety
which is composed of several important steps, to gain a
Laparoscopic cholecystectomy
Subserosal layer
sufficient overview of Calot’s triangle safely. We have
Rouviére’s sulcus safely performed LC for many cases with cholecystitis with
highly inflamed gallbladders using our standardized pro-
cedure [4]. Herein, we present, focusing especially on
prevention of bile duct injuries, our standardized procedure
to achieve the critical view of safety, along with histo-
logical findings.
G. Honda (&)
T. Iwanaga
M. Kurata
F. Watanabe

H. Satoh
K. Iwasaki
Department of Surgery,
Tokyo Metropolitan Cancer and Infectious Diseases Center, Anatomy
Komagome Hospital,
3-18-22 Honkomagome,
Bunkyo-ku, Tokyo 113-8677, Japan Histologically, we divided the ss layer of the gallbladder
e-mail: [email protected] wall into an inner (ss-i) layer, which consists of abundant

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vasculature and some fibrous tissue, and an outer (ss-o) laparoscopic. More specifically, almost the whole ss-o
layer, which consists of abundant fat tissue [4]. We histo- layer (the fat tissue) is stripped away en bloc from the ss-i
logically confirmed that the reticulated dark green layer layer along the border of these layers. Then, it is important
that is exposed by ablating the serosa and fat tissue (ss-o that this exposed surface (the ss-i layer) is kept and
layer) around the gallbladder in LC is, in fact, the ss-i layer extended bluntly and consecutively after first being
(Fig. 1). In almost all cholecystitis cases that have an acquired.
inflamed gallbladder, it is easier to expose the ss-i layer,
because the ss-i layer becomes tough by fibrotic change [4]. Exposing the ss-i layer at the superior (ventral) border
Rouviére’s sulcus is the notch of the liver’s surface by of Rouviére’s sulcus
which the Glissonian pedicle of the posterior segment
enters from the hilum. Therefore, the superior (ventral) At the right hepatic lobe side of the gallbladder, flipping
border of Rouviére’s sulcus leads to the border line Hartmann’s pouch and recognizing Rouviére’s sulcus, first
between the gallbladder body and Glissonian pedicle of the we open only the serosa of the gallbladder above the border
posterior segment (Fig. 2). line with the Glissonian pedicle of the posterior segment by
electrocautery. Then, dissecting or ablating the fat tissue
(the ss-o layer) as bluntly as possible, we expose the ss-i
Technique layer of the lower body of the gallbladder precisely.
Especially when it is hard to expose the cystic duct, we first
The basic procedure intentionally expose the ss-i layer at the lower body. The
most important reason is for safety, and another reason is
We first open the serosa (or the covering peritoneal sheath) that the ss-o layer is usually thin at the lower body in the
and then dissect or ablate all the fat tissue except for other right lobe side, so much so that the ss-i layer can be seen
important structures (organs and vessels). This is similar to directly through the serosa (Fig. 2).
other gastrointestinal surgeries, either open or
Expanding the frontage to the bottom

Next, keeping this layer, we extend that surface toward the

liver bed and the cystic duct by dissecting the serosa and
the fat tissue (the ss-o layer). Simultaneously, we extend
that surface also toward the dorsal side of the lower body as
wide as possible, visually confirming the ss-i layer surface.

Fig. 1 Microscopic view of the resected gallbladder wall (H&E stain,

940). The subserosal (ss) layer can be divided into the ss-i (inner)
layer and the ss-o (outer) layer. The ss-i consists of many vascular and Fig. 2 Recognizing Rouviére’s sulcus (arrowhead) and exposing the
some fibrous tissue. The ss-o consists of much fat tissue. While the ss-i layer of the body at the right hepatic lobe side of the gallbladder.
serosa (s, the visceral peritonea) and ss-o remain on the left side, The superior (ventral) border of Rouviére’s sulcus leads to the border
the exposed ss-i layer with sparse fat tissues of ss-o is observed on the line between the gallbladder body and Glissonian pedicle of the
right side. The layer steps, which were made as the result of exposing posterior segment (arrow). The ss-i layer of the gallbladder body has
the ss-i layer on the right side during LC, are seen (arrows). been exposed above this border line, while the Glissonian pedicle
m Mucosa, mp muscularis propria under this border line has been preserved completely

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Fig. 4 The infraportal posterior hepatic duct (arrow). This scheme is

Fig. 3 Expanding the frontage to the bottom and tunneling. To described as a condition after the cholecystectomy. The arteries are
extend the ss-i layer surface toward the dorsal side of the lower body left out in this scheme. Liver bed, the ss-o layer of the liver bed (the
with confirming that surface visually, we extend further that surface cystic plate), which is left on the liver after the cholecystectomy; RS,
toward the bottom of the gallbladder near the liver bed at the both Rouviére’s sulcus; Ant HD, the hepatic duct of the anterior segment;
sides (arrows). Then, confirming visually and keeping that surface, Post HD, normal hepatic duct of the posterior segment (the
we tunnel bluntly and make the communicated surface from the left supraportal posterior hepatic duct); Rt PV, the right portal vein;
lobe side to the right lobe side. Bottom the bottom of the gallbladder Stump of CD, the stump of the cystic duct

To confirm the ss-i layer surface visually, we further extend

that surface toward the bottom of the gallbladder near the
liver bed. We call this step ‘‘expanding the frontage to the
bottom’’ (Fig. 3). Here, the gallbladder is born off gradu-
ally from the right hepatic artery and the right or aberrant
posterior hepatic duct (most of them are probably the
infraportal posterior hepatic duct) (Fig. 4). Thus, these
artery and ducts can get around injuries without being
exposed (Fig. 2).
Also at the left hepatic lobe side of the gallbladder, we
open the serosa and dissect or ablate the fat tissue (the ss-o
layer) in Calot’s triangle, as with the counter side. When it
is hard to recognize the cystic duct, we expand the frontage
to the bottom and intentionally expose the ss-i layer at the
lower body near the liver bed, also on this side (Figs. 3 and Fig. 5 Expanding the frontage to the bottom and tunneling in a case
of cholecystitis. The ss-i layer surface has been extended further
5). Then, keeping this layer and preserving the cystic
toward the bottom near the liver bed at the left lobe side (arrows).
arteries (they do not necessarily have to be preserved as Tunneling has been undergone by the cylindrical suction instrument
described later), we dissect the fat tissue and extend that bluntly from the left lobe side to the right lobe side

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Then we transect the cystic duct without intraoperative

cholangiography in principle.

Discussion

The reticulated dark green layer that is exposed by ablating

the serosa and fat tissue around the gallbladder has not
been described histologically in previous articles, except
for our previous one [4]. However, we consider that
exposing the ss-i layer is important to achieve the critical
view of safety, and therefore, our procedure should become
standard.
During cholecystectomy, if the full-thickness wall of the
gallbladder, which involves the cystic plate, is dissected
from the bottom toward the neck (the dome down tech-
nique), severe vasculo-biliary injuries are apt to occur, as
Strasberg described [5], because the Glissonean pedicle of
the anterior segment, which connects to the cystic plate, is
pulled out with the cystic plate, and it is often difficult to
Fig. 6 The cystic plate close to the hilar plate leads to the Glissonean
recognize the border between the hepatic duct of the
pedicle of the anterior segment. When the whole cystic plate (the ss-o anterior segment and the cystic plate close to the hilar plate
layer) is dissected from the liver, the hepatic duct of the anterior (Fig. 6). On the other hand, in our standardized procedure,
segment is put in danger, because the Glissonean pedicle of the the cystic plate of the liver is sure to be left, because it is
anterior segment, which connects to the cystic plate, is pulled out
toward the direction indicated by the red arrow. Liver bed, the
the ss-o layer. We consider that this is one of the most
exposed liver parenchyma without remnant fat tissues (the ss-o layer); important points for safety. Strasberg described that the
Cystic plate, the whole ss-o layer dissected from the liver bed; Post base of the liver bed should be exposed and should become
HD, the hepatic duct of the posterior segment; Ant HD, the hepatic visible when the critical view of safety has been achieved
duct of the anterior segment; Rt PV, the right portal vein; Stump of
CD, the stump of the cystic duct
[2]. However, to avoid injuring the hepatic duct of the
anterior segment, the cystic plate (the ss-o layer) should be
left. To leave the cystic plate and to maintain safety, it is a
surface toward the liver bed and the cystic duct. Simulta- very useful step to expand the frontage to the bottom.
neously, we extend that surface toward the dorsal side of Wijsmuler et al. reported that transection of the cystic
the lower body, visually confirming that surface. artery before transection of the cystic duct can optimize the
critical view of safety by giving a better overview of
Tunneling Calot’s triangle [6, 7]. During our standardized procedure,
in which we can preserve the whole outside structures of
Here, we expose the ss-i layer bluntly in the dorsal side of the ss-i layer (bile ducts, hepatic arteries) precisely,
the lower body from both sides and finally tunnel from the peripheral branches of the cystic arteries are exposed at the
left lobe side to the right lobe side, and make a commu- border of the ss-i layer. These arteries are observed
nicated surface of the ss-i layer behind the lower body intruding into the ss-i layer at an extreme angle. Therefore,
(Figs. 3 and 5). We call this step tunneling. Furthermore, we can transect them according to need without hesitation
we extend that communicated surface until the cystic duct before achieving the critical view of safety. We consider
is exposed completely. We also extend that communicated this to be the reason why the cystic arteries must not
surface to the liver bed sufficiently. necessarily be preserved before achieving the critical view
of safety.
Stripping away ss-o from ss-i en bloc Applying this standardized procedure, we have safely
performed LC for not only normal gallbladder cases, but
With these steps, we achieve the critical view of safety also many highly inflamed gallbladder cases without
without injury of the bile ducts and the hepatic arteries, intraoperative cholangiography [4]. Of course, if the
even without seeing them, because we strip away almost critical view of safety cannot be achieved even by this
the whole ss-o layer en bloc from the ss-i layer along the procedure, cholangiography or conversion to open cho-
border of these layers. lecystectomy must be selected to define the ductal

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J Hepatobiliary Pancreat Surg (2009) 16:445–449 449

anatomy. In cases with aberrant anatomy of the bile 2. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of
duct, because we strip away almost the whole ss-o layer biliary injury during laparoscopic cholecystectomy. J Am Coll
Surg. 1995;180:101–25.
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layers, the bile ducts and the hepatic arteries are pre- cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543–7.
served, without being seen. However, in cases with an 4. Honda G, Iwanaga T, Kurata M. Dissection of the gallbladder from
accessory bile duct that joins with any part of the gall- the liver bed during laparoscopic cholecystectomy for acute or
subacute cholecystitis. J Hepatobiliary pancreat Surg. 2008;15:
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GJ, Lange JF. Optimizing the critical view of safety in laparo-
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safety in laparoscopic cholecystectomy by clipping and transecting
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