A technique for laparoscopic cholecystectomy: wide opening of Calot’s triangle as the first step

Abstract

Background Bile duct injury is the most dreaded complication of laparoscopic cholecystectomy. This injury may be avoided by widely opening Calot’s triangle before dissecting the cystic duct and artery. Method During laparoscopy the common bile duct (CBD) and hepatic artery are identified together with the gallbladder neck, which is retracted with a grasper. The operation is carried out in three stages. (I) The initial dissection is undertaken in an anatomical space flush with the gallbladder wall. The posterior gallbladder peritoneum is divided first, beginning on the gallbladder neck, which is then retracted downwards. The anterior gallbladder peritoneum is now divided, again beginning on the gallbladder neck at a distance from the liver. The gallbladder neck is then retracted upwards and downwards to facilitate section of fibrous tissue flush with the gallbladder wall, at a distance from both the liver and the cystic duct and artery, until Calot’s triangle is widely opened. (2) The cystic duct and artery are pulled perpendicular to the CBD and are dissected safely at a distance from the CBD. The cystic artery is clipped, and cholangiography is undertaken before clipping the cystic duct. (3) The fundus and body of the gallbladder are detached from the liver. Results Laparoscopic cholecystectomy was undertaken by this means in 220 patients without a single bile duct injury. There were 70 patients with acute cholecystitis, and the overall conversion rate to open operation was 8%. Discussion This technique assists the detection of anatomical abnormalities and the avoidance of injury to the CBD, right hepatic duct and right hepatic artery. Cholangiography allows the detection of bile duct injuries and once it has been undertaken, bile duct injury cannot occur as the neck of gallbladder has been widely detached from the liver. The technique that starts with wide opening of Calot’s triangle is a safe routine that can even be applied to acute or gangrenous cholecystitis.