Minimizing Complications and Conversions in Laparoscopic Cholecystectomy using a Systematic Dissection Algorithm and Laparoscopic Biliary Ultrasound

Background: Laparoscopic Cholecystectomy (LC) is performed by an astonishing variety of techniques, yet the frequency of biliary injury remains high, and up to 25% of urgent cholecystectomies are performed by open approach. Laparoscopic biliary intraoperative ultrasound (IOUS) allows for identification of biliary anatomy before division of or damage to any structure, but is underutilized. The authors report use of a systematic dissection algorithm for laparoscopic cholecystectomy, aided by routine IOUS.

Methods: A retrospective review was performed of all patients who underwent cholecystectomy by a single surgeon at a single academic institution between January 2005 and May 2007. Of the 65 patients, 43 (66%) had an urgent operation and 20 (31%) were male. IOUS was used in 50 patients. Mean age was 37.4 years and median ASA class II. All patients underwent laparoscopic approach.

Results: A surgical resident was primary surgeon on all cases. Mean operative time was 89 minutes (range 45 to 196). The dissection algorithm consisted of first fully releasing the peritoneal attachments of the gallbladder, followed by assessment of the complexity of cystic duct dissection. In increasing complexity, the following dissection techniques were then applied: direct critical view (77%), infundibulum down approach (6%), fundus down approach (6%), or open infundibulum approach (11%). IOUS was utilized in 50 patients, 64% of whom underwent operation for an acute condition. Complete biliary anatomy was visualized in 48/50 patients (96%). IOUS identified significant biliary abnormalities, altering the operative approach in 20 patients (40%). These abnormalities included presence of a short cystic duct (

Session: Poster

Program Number: P328

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