VALUE OF CRITICAL VIEW OF SAFETY TECHNIQUE IN LAPAROSCOPIC CHOLECYSTECTOMY

Khaled Safwat MD, Abd Elhafez El Shewail MD, Abd Elrahman Metwalli MD, Gamal Osman MD, Waleed Abd Elhady MD, Muhammad Baghdadi MD, Tamer El Shahidy MD and Saad Nagy Msce. General Surgery department, Faculty of Medicine, Zagazig University, Egypt. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


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cholecystectomy. (Nijssen et al., 2014). The CVS has 3 requirements. First, the triangle of Calot must be cleared of fat and fibrous tissue. The second requirement is that the lowest part of the gallbladder should be separated from the cystic plate. The third requirement is that 2 structures, and only 2, should be seen entering the gallbladder. Once these 3 criteria have been fulfilled, CVS has been attained . (Strasberg and Brunt ,2010). This would have prevent accidental biliary and vascular injuries due to uncommon variations, incautious bleeding control or unclear anatomy, so The patient is protected precisely because the surgeon cannot usually achieve a misleading view (Vettoretto et al., 2011). So this technique considered as the gold standard for resident teaching, because it has a lower rate of biliary and hemorrhagic complications, has a shorter operative time, builds self-confidence, and is a simple standardized method both for complicated and uncomplicated gallbladder lithiasis .

Techniques:-
The patient is placed in a supine position. Pneumoperitoneum was created by blind puncture with a Veress needle through a subumbilical incision using carbon dioxide .4 Ports were used . In CVS technique, the gallbladder is grasped and retracted cranially toward the right shoulder via the right flank port. Dissection of Calot"s triangle from both its dorsal and ventral aspects is performed using both blunt and electrocautery dissection (Fig.A). Dissection of the gallbladder from the lower part of cystic plate is started from the presumed point of the infundibulum-cystic duct junction (Fig.B). After dissection was completed there were two structures entering the gallbladder, the duct and the artery (Fig.C). The artery then the duct clipped and divided. Then the gallbladder dissected off completely of the liver bed .In the IN technique ,the fundus is retracted cranially toward right shoulder and the infundibulum is retracted laterally, the serosa is incised parallel to the cystic duct and artery, just caudally to the infundibulum edge, then dissecting the duct and artery to open Calot"s triangle. Then the clips are applied on cystic duct and cystic artery After the identification of them. Then they are sectioned between clips, and retrograde cholecystectomy is completed. The gallbladder was placed in a retrieval bag and extracted through the subxiphoidal incision, which was enlarged if necessary. Hemostasis was achieved in the gallbladder bed, and after a thorough saline lavage, a tube drain was placed in cases with rupture gallbladder or intraoperative bleeding. The port incisions closed. All patients had a subhepatic drain for 1 day, started oral intake 6 hours postoperative. Routine postoperative follow up of all patients was done including, Vital signs, Leakage through the drains (bile or blood) , Abdominal pain or distension or Wound infection.

Results:-
The age of the studied patients in group (A) ranging from 25-56 years old with mean 37.8±9.9 and most of the studied patients are females(73.3%) and in group (B) ranging from 23-51 years old with mean 39.5±8.2 and most of the studied patients are females(73.3%). And so there no significant difference regard both age or sex. ( Table (3) as there is no intra operative bleeding occurred in group A while there was intraoperative bleeding in one case in group B. There is no significant association as all cases with no intraoperative bile injury. Table (4) as there is no bile duct injury in both groups. This study shows there is significant association as regard drain insertion between CVS and infundibular groups . Table (5) as we put adrain in 4 cases in group A and 10 cases in group BT his study shows no significant association as all cases with no postoperative bile leak.         year-oldpatient with severe inflammation.The injury occurred duringdissection before the CVS was achieved, in other words there was no injury due to misidentification.As regard drain insertion , we used to put a drain in cases with rupture gallbladder or as ahaemostatic procedure due to minor bleeding. There was significant difference between both groups as regard drain insertion as there was only four cases in group A closed with intra peritoneal tube drains (26.6%) but in group B as there was ten cases with drain insertion(66.7%)(table5

Conclusions:-
 Using the critical view of safety has an important role in decreasing the operative time because of the safe accurate identification of the anatomy that allow the surgeon to proceed without fear of misidentification .  Although there was no significant difference as regard bile duct injury between both techniques but we cannot deny the claimed role in decreasing these injuries as the number of patients in our study wasn"t sufficient to detect the rate of bile duct injury with this technique so, multicenter trials with more large number of patients are required because of the low expected rate of the events.
From the results obtained from this work we recommend:-Using the CVS as a standard technique in all cases of LC to help in decreasing the rate of BDI and operative time. Also to use it in training hospital and residencies as it builds self-confidence to younger surgeons as it overcome the challenge of misidentification and make them feel more secure.  Also we recommend a long term study and a multicenter study to prove obviously the role of the CVS in decreasing BDI .