Rouviere's Sulcus Anatomy and Its Overall Impact on Operative Time and Complications in Laparoscopic Cholecystectomy: A Longitudinal Observational Study.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR.

Objective: To determine the importance of a critical view of safety (CVS) techniques and Rouviere's sulcus (RS) in laparoscopic cholecystectomy (LC) and its relation to biliary duct injuries (BDIs) and to determine the frequency and the type of RS. Design, Setting, and Participants: A descriptive study was carried out among 76 patients presenting to the surgery department of a tertiary care center in Nepal. The study population included all patients in the age group 16-80 years undergoing LC. Outcome Measures: The main outcome of interest was to calculate the percentage of BDIs along with the frequency and the type of RS. Results: A total of 76 patients were enrolled in the study, out of which 57(75%) were female patients with a male-to-female ratio of 1:3 and a mean age of 45.87 ± 15.33 years. Seventy-one (93.4%) patients were diagnosed with symptomatic gallstone disease. The CVS was achieved in 75 (98.7%) of the cases, whereas in 1 case, the CVS could not be achieved, and in the same patient routine LC was converted into open cholecystectomy owing to the difficult laparoscopic procedure. In 56 (73.7%) cases, RS was first visible to the operating surgeons after port installation, alignment, and adequate traction of the gallbladder; in 20 (26.3%) cases, RS was not originally apparent. Conclusion: According to the findings of this study and the literature's critical assessment of safety, this method will soon become a gold standard for dissecting gall bladder components. The technique needs to be extended further, especially for training purposes. Major difficulties can be avoided by identifying RS before cutting the cystic artery or duct during LC.

Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India. A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS). With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. Themajority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about thesegment 4, only 41.9% could correctly describe it. Awareness of the correct direction of thegallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). Themajority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. Themajority (78.7%) practiced to identify thecystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%). Knowledge of COSIC among surgical residents seems to be suboptimal, especially for theCVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Introduction: Laparoscopic cholecystectomy (LC) is the most frequent surgical operation in general surgery. The focus of recent research has been on improving the procedure's safety. Over 80% of healthy livers have Rouviere's sulcus (RVS), which is a natural notch in the right lobe that is present in proximity to the confluence of the bile duct. It is frequently considered an important component of safety during LC. RVS demarcates the area of the common bile duct (CBD) from the liver bed for the gall bladder. This research intends to evaluate the frequency, its relation to CBD, and the critical view of safety (CVS) during LC.Materials and Methods: An observational study was performed in a cohort of 50 patients listed for LC between September 2021 and September 2022. The presence of RVS was confirmed after liver retraction and dissection commenced. After the creation of CVS, its relationship with CBD was documented. Additionally, the position of the cystic lymph node was also documented during the dissection.Results: The findings of this study revealed that out of 50 patients, only 40 (80%) had RVS. However, cystic lymph nodes were present more frequently in 48 (96%) patients. CVS was achieved in all the patients, and it revealed the presence of RVS above the cystic duct-CBD junction in 37 (74%), at the level of the junction in 11 (22%), and in two (4%) where the junction could not be demarcated.Conclusion: RVS is a reliable marker to dissect laterally to CBD while doing LC, which does not require any dissection and can be appreciated early during the procedure. However, its presence along with the cystic lymph node gives a better anatomical understanding of the area of CBD, thereby assisting in conducting the procedure safely.

Rouviere's sulcus (RS) is a horizontal anatomical structure that runs from the caudate process to the right hepatic lobe on the inferior face of the liver. This groove lies along the common bile duct. The study's objective was to identify the frequency, morphology, dimension, direction, and anatomic subtype of RS, as well as to evaluate its utility as a landmark for safe laparoscopic cholecystectomy. This is a prospective observational study conducted across multiple institutions. The study lasted six months (from July to December 2021) and included 192 patients with an age above 16years with symptomatic gallstone who had a laparoscopic cholecystectomy. 192 patients with a mean age of 43.55 ± 11.33years with a female-to-male ratio of 5:1 were analyzed. RS was present in 87.5% of cases, of which deep open type, deep closed type, scar type, and slit type RS were identified in 75%, 22.0%, 1.80%, and 1.2% cases, respectively. In 74.4% of cases, RS was transverse, in 24.4% of cases it was oblique, and in 1.2% of cases, it was vertical. In 97.02% of patients, the RS was at the same level, and in 2.97% of patients, it was lower than the critical view of safety. The most significant advantage of finding the RS is that the common bile duct is located below it, and the cystic duct and artery are located above it. Detection of RS is a predictor of safe laparoscopic cholecystectomy.

Laparoscopic cholecystectomy was introduced into wide practice about 1990, with demonstrated benefit to patients. However, it was associated with a sharp increase in major bile duct injuries. Biliary injuries are morbid, costly, and the source of litigation. Although not usually due to negligence, they are iatrogenic and detract from the value of laparoscopic cholecystectomy. Most major bile duct injuries are due to misidentification. In the “classical injury,” the common bile duct is thought to be the cystic duct and is divided. Aberrant hepatic ducts may also be mistakenly identified as the cystic duct or cystic artery. The Critical View of Safety (CVS) is a method of target identification, the targets being the cystic duct and the cystic artery. Today, CVS is taught and used widely. It is accepted as a good means of identification of the cystic structures and its use is within the standard of care. The purpose of this surgical perspective is to examine whether CVS has reached the status of being the only acceptable method for identification of structures in laparoscopic cholecystectomy. HISTORY OF THE CRITICAL VIEW OF SAFETY The term “Critical View of Safety” was introduced in an analytical review written in response to the sudden increase in biliary injury associated with laparoscopic cholecystectomy.1 CVS is a re-working of a method of secure identification in open cholecystectomy in which the cystic duct and artery are putatively identified, after which the gallbladder is taken off the cystic plate so that the gallbladder is attached only by the 2 cystic structures.2 Only then is secure target identification achieved. In laparoscopic surgery, complete separation of the gallbladder from the cystic plate makes clipping of the cystic structures difficult, so this step was modified to require only that the lower part of the gallbladder (about one-third) be separated from the cystic plate. The other requirements, that is, that the hepatocystic triangle be cleared of fat and fibrous tissue and that 2 and only 2 structures remain attached to the gallbladder, are the same as in the open technique. Intraoperatively, CVS should be confirmed in a “time-out” in which the 3 elements of CVS are demonstrated. After the introduction of CVS in1995, operative notes were studied in an attempt to determine if CVS was used in procedures in which biliary injury had occurred.3 It was found that the method of target identification that was failing was not CVS, but the infundibular technique in which the cystic duct is identified by exposing the funnel shape where the infundibulum of the gallbladder joins the cystic duct. Inflammatory fusion and contraction may cause juxtaposition or adherence of the common hepatic duct to the side of the gallbladder. When the infundibular technique of identification is used under these circumstances, a compelling visual deception may result that the common bile duct is the cystic duct.3 CVS is less susceptible to this deception because more exposure of structures is needed to achieve CVS. Either the CVS is attained, by which time the anatomic situation is usually clarified, or operative conditions such as severe acute or chronic inflammation prevent attainment of the CVS. In the latter case, when the CVS cannot be reached, 1 of several important “bail-out” strategies such as subtotal fenestrating cholecystectomy4 can be employed, thus avoiding bile duct injury. Of course, the CVS should not be seen in isolation, but as an element of an overall schema of a “Culture of Safety in Cholecystectomy” in which other elements such as good bail-out techniques, good access techniques, and other elements of safety are also employed. EFFECTIVENESS OF THE CRITICAL VIEW OF SAFETY There are 2 principal lines of evidence that the CVS is an effective method of target identification. First, there are several reports containing several thousand patients in which CVS was used for target identification without a biliary injury due to misidentification,5,6 whereas, based on an incidence of biliary injury of 3 to 4/1000 cases, about 20 biliary injuries would be expected. Secondly, in studies that have examined the mechanisms of major biliary injury, CVS has rarely been described as the method of target identification.7,8 Taken as a group, these studies are highly supportive of the value of CVS, but from the perspective of evidence-based medicine, they are at a low level of evidence. So, why after 25 years has there not been a randomized trial that compares methods of target identification? The answer lies in the fact that although many major biliary injuries still occur, that is, 2000 to 3000 per year in the USA, the event rate is only about 3 per 1000 cholecystectomies (up from about 1 per 1000 in the era of open cholecystectomy). A randomized trial cannot practically be performed because the event rate is so low that about 4500 patients per arm would be required. Despite the low event rate, biliary injuries are not uncommon because of the huge number of cholecystectomies performed annually—about 800,000 in the USA. Thus, biliary injury has aspects of a rare disease and a common disease. There are also important corollaries. Case series of laparoscopic cholecystectomies are almost always too small to provide insights into the causes of biliary injury. Population studies of thousands of patients are required to have enough events to gain meaningful insights. That is why going back almost 100 years,9 much of what is known about biliary injury has been gleaned not from case series of cholecystectomies, but from case series of the injuries themselves. WHAT CONSTITUTES STANDARD OF CARE? “Standard of care” is the legal term for the duty owed by one person to another and applies to both nonmedical and medical situations (such as driving a car). It is the amount of care that a reasonable person would take to prevent injury to another person. In the medical-legal context, a doctor must use the amount of skill, learning, and care ordinarily used by members of his/her profession in similar circumstances. Whether a given treatment or procedure is acceptably within the standard of care depends on whether it falls within the norms of practice, which are established by professional authorities in writings and recorded electronic communications. In recent years, the evidence presented in these communications has been graded from 1 to 5, with randomized trials being at a very high level, whereas case series and expert opinion are considered weaker evidences. Often several ways of diagnosis or treatment fall within the standard of care. Consensus conferences which weigh the available evidence regarding a type of care may sometimes conclude that there is high level evidence that one particular type of care is superior to all others. That type of conclusion, if based on high levels of evidence, could establish that failure to use a specific type of care in a particular situation will most likely be below the standard. An obvious example would be the failure to use antibiotics in an acute bacterial infection such as cellulitis. Finally, in determining standard of care, an important criterion is whether a type of care is in broad use by qualified surgeons. If it is, even by a moderate percentage of surgeons, then there is a strong argument that it falls within the standard of care. IS THE CRITICAL VIEW OF SAFETY THE ONLY ACCEPTABLE MEANS OF DUCTAL IDENTIFICATION DURING LAPAROSCOPIC CHOLECYSTECTOMY? Critical View of Safety, routine cholangiography, the infundibular technique, visualization of the common bile duct and common hepatic duct, and top-down cholecystectomy are some methods that have been advocated for target identification in cholecystectomy. CVS is not the only method within the standard of care for the following reasons. Textbooks of surgery may10 or may not11 recommend CVS as the method of target identification. The evidence that CVS is superior to all other methods is level 4, that is, case series. No consensus conference has published a guideline that CVS is the only effective method of target identification. Many surgeons in current practice use and are confident in other methods.12 The fact that some experts believe that CVS is the preferred method of target identification in laparoscopic cholecystectomy is insufficient alone to establish it as the only method within the standard of care. Stated otherwise, at this time, CVS is not the only method of ductal identification within the standard of care. PROBLEMS WITH CVS Dissemination of new information is a difficult problem in surgery. Even after more than 20 years, surgeons often have a poor understanding of the criteria for CVS, and may confuse CVS with the infundibular technique.12,13 Reluctance to adopt new techniques or methods can also be a challenge. In the case of CVS, this is compounded by the low event rate of biliary injury, which makes an error trap like the infundibular technique even harder to overcome. If it fails only 1 in 300 times, then it works 299 out of 300 times and there is a huge reservoir of confidence in it.13 Also, the infundibular method is easier and takes less dissection than CVS. Attainment of the CVS is not usually recorded or documented photographically, and although the dictated operative note may state that the CVS was achieved, recent evidence suggests this is frequently not the case.7 FUTURE OF CVS Critical View of Safety is part of the Culture of Safety In Cholecystectomy (COSIC) and this problem has been taken up by SAGES in a novel effort called “Safe Cholecystectomy” (www.sages.org/safe-cholecystectomy-program) The SAGES Safe Cholecystectomy program aims to better disseminate understanding and use of CVS and other strategies for prevention of biliary injury such as use of intraoperative imaging and approaches to the difficult gallbladder that include proper bail-out techniques.4 A multisociety consensus development conference is planned in 2017 on the subject of bile duct injury to study and promote safety in cholecystectomy. The role and application of CVS and other strategies for prevention of biliary injury will be critically examined in that forum. An effective and easy method of photodocumentation of CVS is now available for surgeons who wish to record CVS visually.14 For those who wish to record it in operative notes, it is important to know that CVS cannot be said to have been achieved without attainment of all 3 elements of this method of target identification. We dictate these 3 elements into operative notes and recommend it as an excellent practice. ACKNOWLEDGMENT The authors thank Ms Christine A. Vaporean of the law firm of Brown and James, Saint Louis, Missouri, for helpful discussions and suggestions.

Background:Rouviere's sulcus is a 2–5 cm fissure on the liver between the right lobe and caudate process. The benefit of finding the Rouviere's sulcus during laparoscopic cholecystectomy is supported by the fact that the cystic duct and artery lay anterosuperior to the sulcus, and the common bile duct (CBD) lays below the level of the Rouviere's sulcus. Hence, it can serve as an extrabiliary anatomical reference point during laparoscopic cholecystectomy to identify the location of CBD.Materials and Methods:This prospective observational study was carried out on 99 patients during a period of 1 year. During laparoscopic cholecystectomy, Rouviere's sulcus was identified after retracting the fundus of the gallbladder toward the right shoulder. Its morphology in terms of open type, close type, or scar-like shapes was recorded, and if the CBD outline could be visualized, then its relation with the Rouviere's sulcus was noted.Results:Among all 99 study patients, Rouviere's sulcus could be identified in 63 cases (63.63%), whereas it could not be seen in 36 cases (36.36%) (P < 0.007). It was of open type in 68.25% (43 cases), close type in 25.39% (16 cases), and scar like in 6.35% (4 cases) (P < 0.0001). The Rouviere's sulcus was found to be above the level of CBD line in 50 patients (79.36%) and at the same level in 11 patients (17.46%), and in two patients, (5.97%) CBD line could not be visualized.Conclusion:Identification of Rouviere's sulcus during laparoscopic cholecystectomy can serve as an additional reference point to avoid major bile duct injury. In the era of laparoscopy, it can be better visualized after creating the pneumoperitoneum and retracting the fundus of the gallbladder.

Background Laparoscopic cholecystectomy (LC), introduced in the early 1990s, is now the gold standard for treating gallbladder lithiasis. It offers benefits such as reduced postoperative pain, shorter hospital stays, faster recovery, and lower costs for national healthcare systems, making it a routine surgical procedure. Aim of the Work The study aims to assess the safety of applying the critical view of safety in laparoscopic cholecystectomy, focusing on complications and postoperative stay, among patients at El-Demerdash Hospital from June to December 2023. Patients and Methods This retrospective cohort study will be conducted at the general surgery department of El-Demerdash Hospital from June 2023 to December 2023, aiming to assess the safety of the critical view of safety in laparoscopic cholecystectomy. Results This study aimed to evaluate the effectiveness of the Critical View of Safety (CVS) technique in laparoscopic cholecystectomy by comparing two groups of patients. Group A had CVS applied in 100% of cases, while Group B did not receive this technique. The study focused on postoperative complications and outcomes, providing valuable insights into the role of CVS in improving surgical safety. Both groups were comparable in terms of age, sex, and medical history, ensuring that these factors did not bias the results. The findings revealed a significant difference in the implementation of CVS, with Group A having CVS applied in all cases, while Group B did not receive this technique at all (p &amp;lt; 0.001). This distinction was crucial as CVS is known to reduce the risk of bile duct injuries, a common and severe complication in laparoscopic cholecystectomy. Postoperative complications were absent in Group A, whereas Group B had a 4% complication rate, including bleeding and bile leakage, which highlights the protective effect of CVS in minimizing risks.The study also found that adhesions were the primary cause of complications in Group B (54%), suggesting that CVS may mitigate risks even in challenging cases with prior abdominal surgeries. These results align with existing literature, emphasizing that applying CVS during laparoscopic cholecystectomy significantly reduces the likelihood of complications. Conclusion This study demonstrated that the application of the Critical View of Safety (CVS) technique in laparoscopic cholecystectomy significantly improves patient outcomes by reducing postoperative complications. The results showed that patients in Group A, where CVS was applied in 100% of the cases, had no postoperative complications, whereas Group B, where CVS was not achieved, experienced a 4% complication rate. The findings highlight the crucial role of CVS in minimizing the risk of bile duct injuries and other complications associated with laparoscopic cholecystectomy. The demographic and medical history factors between the two groups were comparable, ensuring that the observed differences in outcomes were primarily due to the implementation of CVS. Given the significant reduction in complications observed in Group A, it is evident that CVS plays an important role in improving the safety of laparoscopic cholecystectomy.

Objective: Researchers described several anatomical landmarks, a method of identification of the cystic structures referred as "critical view of safety", and operative techniques to avoid vascular and biliary injuries due to the laparoscopic cholecystectomy (LC). In this present study, we aimed to determine the frequencies, variations, and significance of Rouviere's sulcus (RS) in the context of difficult laparoscopic cholecystectomy (DLC).

Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results. Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC). There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC. LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Objective: Identification of the Rouviere's sulcus as an extra biliary landmark during laparoscopic cholecystectomy helps to reduce the iatrogenic injuries of common bile duct (CBD). Therefore, this study was carried out to assess its frequency, morphology, and its relation with the CBD in cadaveric liver specimens.Methods: An observational study was carried out in the department of Anatomy, during a period of 2021 -2023. Fifty liver specimens without any previously recorded liver or extra hepatic biliary pathology were dissected and observed. During dissections, Rouviere's sulcus was identified, and its morphology of open type, closed, or scar-like shapes was noted, and the CBD and its relation with the Rouviere's sulcus was observed.Results: Rouviere's sulcus was identified in 35/50 (70%), whereas 15/50 (30%) it could not be seen. Among the 35/50 livers with Rouviere's sulcus, 20 /35 (57%) were of open type, 10/35 (28%) were close type, and scar like seen in 5/35 (15%). Among these 35 liver specimens, in 28/35 (80%) the Rouviere's sulcus was above the level of CBD line. In 5/35 (14%) the sulcus was at the same level. in 2/35 (6%) the sulcus was below the line of CBD.Conclusion: Identification of Rouviere's sulcus can be helpful as an additional landmark as its close relation to CBD.

Background: For gallstones, laparoscopic cholecystectomy is the accepted standard technique. Objectives: This work aimed to ascertain Rouviere's sulcus' frequency and significance as a marker in laparoscopic cholecystectomy procedures. Patients and methods: 155 patients with symptomatic gallstone disease who had laparoscopic cholecystectomy at Menoufia University's National Liver Institute were included in this prospective research. Results: In 20 instances, adhesions were seen, and in 127 cases, the sulcus was apparent. In 109 instances, calot dissection was performed above the level of the Rouviere's sulcus; in 46 cases, it was done at that level. Two cases suffered from biliary complications and another two suffered from blood loss. A total of 46 instances (30%) had the dissection performed at the level of Rouviere's sulcus, and 3 cases (6.5%) had problems. Regarding postoperative data in the study participants, collection was present in 5 cases, biliary leak in 2 cases. Postoperative wound infection occurred in 4 cases and drain in 148 cases. Patients whose Rouviere's Sulcus (RS) was not visible had much longer hospital stays and surgery times than patients whose RS was evident (p <0.001, =0.008, respectively). Conclusion: Rouviere’s sulcus was present in (82%) of the total cases. It could be concluded that a safe laparoscopic cholecystectomy requires a clear identification of this anatomical landmark.

Background: Laparoscopic Cholecystectomy (LC) is the Gold Standard procedure for symptomatic gallstones. With the development of laparoscopic procedure, surgical interest in the Rouviere’s sulcus and cystic lymph node in relation to the right portal pedicle and prevention of bile duct injury has increased recently. This prospective study aimed at safety landmarks for avoiding Bile Duct Injuries during surgery and reducing the number of intraoperative and postoperative complications in laparoscopic cholecystectomy. The aim of the study is to compare the frequency of bile duct injury in conventional method of dissection versus the frequency of bile duct injury by delineating rouviere’s sulcus and cystic lymph node as safety landmark in laparoscopic cholecystectomy. Material and Method: A comparative study was conducted on 60 patients of cholelithiasis who underwent laparoscopic cholecystectomy at our institution in two-year period. All patients were evaluated in terms of clinical, biochemical, haematological and ultrasonographic parameters and randomised in two groups. Patients were allocated group A and B depending upon Ticket picked by them. Group A patient: Rouviere’s sulcus and cystic lymph node was identified intraoperatively and an imaginary line (R4U) that passed from the sulcus across the base of segment 4 to the umbilical fissure drawn and cystic line is an imaginary line running through cystic lymph node and parallel to hepatoduodenal ligament was drawn and dissection superolateral to intersection of these lines along with achievement of CVS. Group B patients: Underwent conventional method of dissection (calot’s Triangle dissection with critical view of safety achievement). Patients were followed up after 7 days and assessment was done. Conclusion : the study concluded that before commencement of calot’s triangle dissection identification of Rouviere's sulcus [RS] and cystic lymph node of lund is an extra biliary, easily accessible and reliable anatomical land mark from where we can draw two imaginary line [R4U and cystic line] and dissection start above and lateral to intersection of these line and no injury was observed and one bile duct injury was noted during convention method of dissection. So it can help us as an additional safe reference point to avoid bile duct injury and dissection in safe area close to gall bladder in laparoscopic cholecystectomy.

Achieving the critical view of safety (CVS) before transection of the cystic artery and duct is important to reduce biliary duct injury in laparoscopic cholecystectomy. To gain more insight into complications after laparoscopic cholecystectomy, we investigated whether the criteria for CVS were met during surgery by analyzing videos of operations performed at our institution. All consecutive patients who underwent a completed laparoscopic cholecystectomy between 2009 and 2011 were included. The videos of the operations of patients with complications were independently reviewed and rated by two investigators with a third consulted in the event of a disagreement. The reviewers answered consecutive questions about whether the CVS criteria were met. Patients who underwent an elective laparoscopic cholecystectomy and had no complications were used as a control group for comparison. Of the 1108 consecutive patients who had undergone a laparoscopic cholecystectomy during the study period, 8.8 % developed complications (average age 51 years) and 1.7 % had bile duct injuries [six patients (0.6 %) had a major bile duct injury, type B, D, or E injury]. In the 65 surgical videos available for analysis, CVS was reached in 80 % of cases according to the operative notes. However, the reviewers found that CVS was reached in only 10.8 % of the cases. Only in 18.7 % of the cases the operative notes and video agreed about CVS being reached. CVS was not reached in any of the patients who had biliary injuries. In the control group, CVS was reached significantly more often in 72 %. In our institutional series of laparoscopic cholecystectomies with postoperative complications, CVS was reached in only a few cases. Evaluating surgical videos of laparoscopic cholecystectomy cases are important and we recommend its use to improve surgical technique and decrease the number of biliary injuries.

Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital