Importance of Critical View of Safety, Rouviere’s Sulcus, and Minimal Energy Device Usage in Reducing Biliary Injury in Laparoscopic Cholecystectomy


Laparoscopic Cholecystectomy
Bile Duct Injury
Critical View of Safety
Rouviere’s Sulcus

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Afaque MY, Rehman N, Alam J, Varshney H, Ali Rizvi SA, Aslam M. Importance of Critical View of Safety, Rouviere’s Sulcus, and Minimal Energy Device Usage in Reducing Biliary Injury in Laparoscopic Cholecystectomy. Surg Insights [Internet]. 2022 Apr. 11 [cited 2024 Jun. 22];. Available from:


Introduction: Major bile duct injury in laparoscopic cholecystectomy results in morbidity and needs further management, which adds to the increased cost of treatment. However, some studies have shown that by defining critical view of safety and seeing the relationship of Rouviere's sulcus with other structures, and minimal use of diathermy in Calot's triangle, we can bring down complications further close to zero percent. We wanted to see that such a low bile duct injury rate is achievable at every center by routinely following these steps. We retrospectively reviewed the database of patients who had undergone elective laparoscopic cholecystectomy (LC) in three years and evaluated the rate of bile duct injury and other complications.
Methods: We reviewed our database for patients and did a retrospective analysis on patients who were diagnosed with symptomatic cholelithiasis or chronic cholecystitis, and have undergone LC in our centre from January 2017 to December 2019. Patients less than 15 years of age, acute cholecystitis, and laparoscopic cholecystectomy combined with common bile duct exploration were excluded. We calculated the incidence of biliary injury. The secondary outcomes looked at were Veress needle or pneumoperitoneum-related complications, port site bleeding, intra-abdominal bleeding, bowel injury, liver injury, wound infection, and early port site hernia.
Results: LC was performed in 642 patients. In this study, there was no bile duct injury. Two patients (0.31%) had minor bile leak which resolved without any intervention within a week. Three (0.46%) patients developed port site infection, which responded to regular dressing and oral antibiotic therapy.
Conclusion: The effectiveness of these steps should make their use mandatory in every center to reduce bile duct injury.


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