Review
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2016; 22(47): 10287-10303
Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10287
Protocol for laparoscopic cholecystectomy: Is it rocket science?
Tomohide Hori, Fumitaka Oike, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Masato Naito, Masaya Nakauchi, Takahiro Tanaka, Daigo Gunji, Kiyokuni Nakamura, Kiyoko Sato, Masahiro Mizuno, Taku Iida, Shintaro Yagi, Shinji Uemoto, Tsunehiro Yoshimura
Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan
Fumitaka Oike, Masato Naito, Masaya Nakauchi, Takahiro Tanaka, Daigo Gunji, Kiyokuni Nakamura, Department of Gastrointestinal Surgery, Mitsubishi Kyoto Hospital, Kyoto 615-8087, Japan
Kiyoko Sato, Department of Anesthesiology, Mitsubishi Kyoto Hospital, Kyoto 615-8087, Japan
Masahiro Mizuno, Department of Gastroenterology and Hepatology, Mitsubishi Kyoto Hospital, Kyoto 615-8087, Japan
Taku Iida, Shintaro Yagi, Shinji Uemoto, Department of Hepatobiliary Pancreatic Surgery, Kyoto University Hospital, Kyoto 606-8507, Japan
Author contributions: Hori T and Oike F created the initial protocol for laparoscopic cholecystectomy, and both authors thereafter further revised the protocol; Hori T drew all illustrations and schemas, collected the data, performed the statistical analyses, and wrote the review; Furuyama H, Machimoto T, Kadokawa Y, Hata T, Kato S, Yasukawa D, Aisu Y, Sasaki M, Kimura Y, Takamatsu Y, Naito M, Nakauchi M, Tanaka T, Gunji D, Nakamura K, Sato K, Mizuno M, Iida T and Yagi S provided academic opinions on the review and helped to assess important papers; Oike F, Uemoto S and Yoshimura T supervised this review.
Conflict-of-interest statement: Neither author has a potential conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Tomohide Hori, PhD, MD, FACS, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, 200 Mishima-cho, Tenri 632-8552, Japan. horitomo@tenriyorozu.jp
Telephone: +81-743-635611 Fax: +81-743-631530
Received: July 30, 2016
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
Processing time: 142 Days and 13.2 Hours
Abstract

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.

Keywords: Laparoscopic cholecystectomy; Gallbladder; Critical view of safety; Biliary injury; Protocol

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.