Laparoscopic cholecystectomy (LC) is considered as the gold standard for management of cholelithiasis. After introduction in the early 1990s, this procedure has gained excellent consensus and has become a routine surgical procedure. The main techniques used in laparoscopy are the “infundibular technique” and intraoperative identification of the cystic duct for gallbladder (GB) hilar dissection using laser electrocautery [1].

LC provides several advantages for the patient over open cholecystectomy. These advantages include less pain, reduced hospitalization time, and faster recovery. However, the introduction of LC has been associated with a considerable rise in the incidence of major bile duct injury from about 1 per 1,000 to 3 per 1,000 (Tornqvist et al., 2012). Other studies have shown a complication rate of about 10% higher (0.1-1.5%) when compared with the open procedure. Bile duct injuries (BDI) cause considerable morbidity and require additional costs and reduce the value of the procedure and the patient's quality of life [2].

The basic principles of performing laparoscopic cholecystectomy include a thorough knowledge of the anatomical landmark, identification of predictive factors for difficult cholecystectomy, proper understanding, and execution, including the proper appearance of the hepatocystic triangle in preparation for dissection, achieving a critical view of safety (CVS), strategies for dealing with difficult situations and documentation [3].

Anatomy, disease-related pathology, misidentification of anatomical structure, and incorrect technique are all risk factors for BDI or vasculobiliary damage. Misidentification of the common bile duct (CBD) or common hepatic duct (CHD) as the cystic duct, or inaccurate identifying of the hepatic artery as the cystic artery, is the most common mechanism of injury [4]. The CVS is a frequently utilized preventative approach that involves detecting the Calot triangle. Additional treatment for BDI ranges from endoscopic retrograde cholangiopancreatography (ERCP) through restorative surgery and, in certain cases, liver transplantation, resulting in major increases in expenses, surgical morbidity, and death [1,5].

54 patients underwent LC for GB disease from January 2017 to December 2019 at the digestive surgery sub-division of Moewardi Hospital Surakarta. The following is a LC procedure with a Triangle of Safety approach, according to Almutairi & Hussain [6]. The surgery was carried out utilizing the traditional four-port method. Using the "flip over" approach over the liver's right lobe, the GB is retracted from the fundus. Through the second port, the anterior margin of Hartman's pouch is retracted outward and laterally, making room for the triangle of safety.

The boundaries of the triangle of safety are dissected into 4 essential steps using electrocautery hooks: The initial step is to dissect the peritoneum from the middle to the junction of the cystic artery and duct over the GB wall laterally and parallel to the cystic artery. 

The second stage involves dissecting the minor branches of the dilated cystic artery in the GB wall beneath the peritoneal layer until the dissection reaches the little branch that connects the cystic artery to the cystic duct "Calot's artery" and forming a connection there. Identifying the branches is simple, and the edema of the inflamed GB wall makes it easier. As a result, the GB is freed from its medial peritoneal location, allowing the cystic artery to fall and create the medial boundary of the triangle of safety, as well as opening two other boundaries: the GB posterior wall and the cystic-infundibular duct junction.

The lateral peritoneal attachments must be released in the third phase. The fourth step is to separate the tissue between the triangle of safety along the GB wall, which reaches the lateral side while avoiding the posterior cystic artery branch. To avoid dissection and probable damage at the common hepatic duct, the cystic artery above the GB wall is clipped and divided more precisely in Calot's triangle. The cystic artery is clipped and divided, resulting in the cystic duct, which can be cleaved near its junction with the GB infundibulum.

Figure: 1 The port location of laparoscopic cholecystectomy [6]

Table 1. Research Subjects Characteristics

There were 54 patients, 16 men (29.6%) and 38 women (70.4%), with the youngest 19 years old and the oldest 85 years old, primarily found in the 51-60 years age group (29.62%). All actions were performed under elective operating conditions. Patients who changed to open cholecystectomy before GB dissection was initiated due to severe adhesions were two patients (3.7%).

Indications for LC are symptomatic cholecystitis and calculous cholecystitis. There were 1 patient (1.85%) with GB polyps. All patients complained of biliary colic pain as the chief complaint. There were no complications or intraoperative complications such as anatomic abnormalities, severe tissue inflammation, visceral trauma, bleeding, or biliary duct injury.

Cholecystectomy is a common gastrointestinal surgical treatment, and the laparoscopic method is the gold standard for symptomatic cholecystolithiasis and acute and chronic cholecystitis [7]. With an incidence of 0.3–0.7%, biliary tract damage is the most serious complication of LC, resulting in decreased quality of life, overall survival, and medicolegal issues [8].

Prevention of injury to the ductal system continues to be a concern for surgeons performing LC. The critical view of safety (CVS) by identifying Calot's triangle is a biliary injury prevention method widely used today. Studies show an approximately 10% higher complication rate (0.1-1.5%) in laparoscopic cholecystectomy compared with open cholecystectomy [9].

Strasberg's CVS approach, which identifies biliary structures during dissection, is the gold standard for executing a safe cholecystectomy. The "infundibular approach," which works very near to the GB infundibulum and reduces the danger of biliary damage, is another option. Other techniques include anatomical structures such as the Rouviere sulcus, Calot's triangle, and the B-SAFE method (B, bile duct; S, sulcus of Rouviere; A, hepatic artery; F, umbilical fissure; E, enteric/ duodenum) [10,11,12,13] . To identify the cystic duct and cystic artery, the operator must know the safe dissection zone. 

The majority of biliary damage are discovered after surgery, with 30% occurring after the patient has been discharged. The key indications and symptoms vary depending on the type of injury. Biliary leakage symptoms include abdominal pain, soreness, fever, and indicators of sepsis. Icterus might be a sign of biliary strictures. Nausea and vomiting, tachycardia, weakness, and anorexia are common symptoms in both types of injuries. Cholestatic enzymes (liver function tests) are high. Cholangitis is the most common symptom in these patients [14].

Figure 2: Trigonum of calot

Several methods have been shown to reduce ductal injury, including routine intraoperative cholangiography and prior fundal dissection techniques. Intraoperative cholangiography, injection of radiopaque contrast into the bile duct, and then using an image amplifier to view the duct system may be helpful to confirm these anatomic anomalies but is not always reliable. To avoid misidentification of the ducts, many rules have been proposed, including instructions for direct traction of the GB [3,15].

The predisposing factors for BDI or vasculobiliary injury are anatomy, disease-related pathology, structural errors of identification, and improper technique. Cystic duct abnormalities such as short cystic duct, cystic duct parallel to CVD, existence of hepatocystic duct, auxiliary cystic duct, and presence of bile duct deviation (e.g., Luschka's duct) can all induce iatrogenic diseases [16]. As many as 97% of biliary duct injuries occur due to visual perceptual illusions that incorrectly identify the bile duct as the cystic duct. According to Strasberg, no clipping or cutting should be done until the Calot's triangle is free of any fatty components, allowing only the cystic artery and duct to be seen. The attending surgeon, on the other hand, chooses the procedure that is the safest [2,17,18].

Because failure to identify arteries should be a concern for surgeons with anomalies in the arterial and ductal system, the Triangle of Safety method, which starts with dissection of the GB wall, then identification of the cystic artery, and finally the junction of the cystic and infundibular ducts, can help reduce misperception errors. Another benefit of the Triangle of Safety procedure is that it keeps the GB infundibulum away from the liver floor, revealing the possibility of a small or hidden cystic duct, by dividing the peritoneum and branches of the cystic duct across the GB wall to open the Triangle of Safety. The cystic artery and duct anomalies are most common at the level of Calot's triangle, according to the literature. Anomalies of the cystic artery and duct are most common at the level of Calot's triangle, according to the literature; the Triangle of Safety approach avoids this area [6].

Figure 3 Triangle of safety, cystic artery (white arrow), and branch between cystic duct and artery (black arrow) [6]

From January 2017 to December 2019, 54 patients underwent a LC in the digestive surgery sub-division of Moewardi Hospital, Surakarta, using the Triangle of Safety method. There were no complications, either bleeding or biliary injury.

Because it shows the structure of the cystic duct and lowers the risk of misidentification and the necessity for intraoperative cholangiography, the Triangle of Safety approach is safe for LC. This approach performs the dissection away from the Calot's triangle, where no ductal or artery abnormalities need to be treated, reducing intraoperative and postoperative problems.

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2. Strasberg, S.M. “A Perspective on the Critical View of Safety in Laparoscopic Cholecystectomy.” Annals of Laparoscopic and Endoscopic Surgery, vol. 2, no. 5, 2017, pp. 91–91.

3. Törnqvist, B., et al. “Effect of Intended Intraoperative Cholangiography and Early Detection of Bile Duct Injury on Survival after Cholecystectomy: Population-Based Cohort Study.” BMJ, vol. 345, Oct. 2012, e6457.

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7. Almutairi, A.F., and Y.A.M.S. Hussain. “Triangle of Safety Technique: A New Approach to Laparoscopic Cholecystectomy.” HPB Surgery, 2009, pp. 2–6.

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10. Pucher, P.H., et al. “Outcome Trends and Safety Measures after 30 Years of Laparoscopic Cholecystectomy: A Systematic Review and Pooled Data Analysis.” Surgical Endoscopy, vol. 32, no. 5, May 2018, pp. 2175–2183.

11. Pesce, A., et al. “Utility of Fluorescent Cholangiography During Laparoscopic Cholecystectomy: A Systematic Review.” World Journal of Gastroenterology, vol. 21, no. 25, July 2015, pp. 7877–7883.

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13. Singh, M., and N. Prasad. “The Anatomy of Rouviere’s Sulcus as Seen During Laparoscopic Cholecystectomy: A Proposed Classification.” Journal of Minimal Access Surgery, vol. 13, no. 2, 2017, pp. 89–95.

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18. Pesce, A., et al. “Iatrogenic Bile Duct Injury: Impact and Management Challenges.” Clinical and Experimental Gastroenterology, vol. 12, Feb. 2019, pp. 121–128.

19. Strasberg, S.M., and L.M. Brunt. “Rationale and Use of the Critical View of Safety in Laparoscopic Cholecystectomy.” Journal of the American College of Surgeons, vol. 211, no. 1, July 2010, pp. 132–138.