Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

Table 1 Predictors of difficult cholecystectomy[39,40,71]

History

Male gender

Higher age (> 65 yr)

Increased interval between onset and presentation (> 72-96 h) in acute cholecystitis

Previous multiple attacks of biliary colic

History of acute cholecystitis

Upper abdominal surgery

Prior attempt at cholecystectomy (including cholecystostomy)

Physical examination

Fever

Higher ASA score

Morbid obesity

Laboratory tests

Raised leucocyte count (> 18000/mm3)

Raised C-reactive protein

Imaging (USG/CT/MRI-MRCP)

Thick walled gallbladder (> 4-5 mm)

Small contracted gallbladder

Distended gallbladder with impacted stone in neck

Gangrenous gallbladder/gallbladder perforation

Mirizzi syndrome/Cholecystoenteric fistula

Cirrhosis/extrahepatic portal vein obstruction (portal cavernoma) with portal hypertension

Intraoperative

Small shrunken gallbladder not visualized on initial exploration

Liver edge retracted with fissure/depression/puckering near fundus (Liver pucker sign, Figure 3C)

Fatty/firm cirrhotic liver (difficulty in retraction)

ASA: American Society of Anesthesiologist; USG: Ultrasonography; CT: Computed Tomography; MRI-MRCP: Magnetic resonance imaging-magnetic resonance cholangiopancreatography.

Table 2 Concept of “time out”

Use B-SAFE to be safe
To be safe: Use time-out
Aim: Reorientation/reassessment
What to do: Stop→Wait→Reassess→Act
What to see: B-SAFE
When to see
1 Before beginning dissection in hepatocystic triangle
2 Whenever there is any doubt about anatomy
3 After achieving CVS and before dividing cystic duct and artery (define, decide and then divide)

B-SAFE: Surgical landmarks; CVS: Critical view of safety.

Table 3 Stopping rules: Identification of “Red flags”[38]

Stopping rules
More than 2 tubular structures entering gallbladder
Unusually large presumed cystic artery (this may be hepatic artery)
Large artery pulsations present behind the presumed cystic duct (this duct may be common hepatic/bile duct)
Medium-large clip fails to occlude ductal lumen (this duct may be hepatic/bile duct)
Large ductal structure that can be traced behind the duodenum (this duct is common bile duct)
Excessive fibrofatty/lymphatic tissue noted around the presumed cystic duct (this may be common hepatic/bile duct)
Bile leak seen with intact gallbladder
Bleeding requiring blood transfusion