Laparoscopic cholecystectomy is the gold standard procedure for the treatment of symptomatic gallstone disease. In most patients, it is straightforward and safe. However, in a subset of cases, the surgery becomes difficult due to distorted anatomy, dense adhesions, or severe inflammation, especially in Calot’s triangle. These challenging scenarios demand advanced surgical techniques to ensure safety and to prevent injury to vital structures such as the common bile duct (CBD), hepatic artery, and portal structures. One such technique is the use of pledget dissection for precise and careful handling of Calot’s triangle.

Why Laparoscopic Cholecystectomy Becomes Difficult

Several factors contribute to difficult laparoscopic cholecystectomy:

Acute or chronic cholecystitis leading to fibrosis and scarring

Empyema or mucocele of gallbladder causing tissue friability

Dense adhesions involving omentum, duodenum, or colon

Contracted or shrunken gallbladder obscuring normal landmarks

Anomalous biliary anatomy increasing risk of injury

Previous upper abdominal surgery causing adhesions

In these cases, Calot’s triangle, the critical area bordered by the cystic duct, common hepatic duct, and inferior surface of the liver, becomes difficult to dissect safely.

Importance of Calot’s Triangle in Cholecystectomy

Proper identification of structures within Calot’s triangle is essential to achieving the Critical View of Safety (CVS), which requires:

Clearance of fibrofatty tissue in the triangle.

Exposure of only two structures entering the gallbladder (cystic duct and cystic artery).

Separation of the lower gallbladder from the liver bed.

Failure to achieve CVS can result in bile duct injuries, one of the most dreaded complications in biliary surgery.

Pledget Dissection: A Safe Alternative

When conventional methods like sharp dissection, monopolar cautery, or blunt dissection are unsafe due to inflammation and fibrosis, pledget dissection provides a controlled technique.

What is a Pledget?

A pledget is a small piece of soft surgical material, often made from cotton, gauze, or Teflon, used as a blunt dissector. When mounted on a laparoscopic grasper, it becomes an atraumatic instrument to peel tissues layer by layer.

Technique of Pledget Dissection

Exposure: The gallbladder is retracted upward and laterally to open the Calot’s triangle.

Mounting the Pledget: A small cotton pledget is held firmly with a laparoscopic grasper.

Gentle Sweeping Motions: Instead of cutting, the pledget is used to sweep away fibrofatty tissue covering the cystic duct and artery. This avoids inadvertent thermal or sharp injury.

Hydro-dissection Option: In some cases, irrigation with saline is combined with pledget dissection to separate tissues more easily.

Achieving CVS: Once the cystic duct and cystic artery are clearly visualized, they can be safely clipped and divided.

Advantages of Pledget Dissection

Atraumatic: Minimizes risk of injury to bile ducts and vessels.

No Thermal Damage: Unlike cautery, there is no risk of thermal spread to nearby structures.

Precision: Allows layer-by-layer dissection even in dense fibrosis.

Low-cost: Readily available material, no expensive equipment required.

Case Example: Difficult Cholecystectomy

In cases of acute cholecystitis, the gallbladder is often thickened, and Calot’s triangle is obscured by dense inflammatory adhesions. Attempting dissection with cautery may cause bleeding or bile duct injury. Here, Dr. R. K. Mishra and other expert laparoscopic surgeons often demonstrate the use of pledget dissection. By slowly sweeping away adhesions with a pledget, the anatomy is clarified without trauma, allowing the surgeon to achieve the Critical View of Safety and complete the cholecystectomy successfully.

When to Consider Pledget Dissection

Severe inflammation or scarring at Calot’s triangle

Cases where thermal energy could endanger adjacent structures

Distorted biliary anatomy

Difficult reoperative biliary surgeries

Pediatric or thin-walled gallbladders where precision is vital

Limitations of Pledget Dissection

Time-consuming compared to standard dissection methods

Requires patience and skill to avoid incomplete tissue clearance

May not be sufficient in cases of massive adhesions or unclear anatomy, where conversion to open surgery is safer

Integration with Other Techniques

Pledget dissection is often combined with:

Fundus-first (top-down) approach in very difficult cases

Intraoperative cholangiography to confirm ductal anatomy

Subtotal cholecystectomy when anatomy remains uncertain

Conversion to open surgery if safe laparoscopic dissection is not possible

Conclusion

Difficult laparoscopic cholecystectomy remains a test of surgical judgment, patience, and technique. In such situations, achieving the Critical View of Safety is non-negotiable to prevent catastrophic bile duct injuries. Pledget dissection of Calot’s triangle provides surgeons with a safe, effective, and low-cost method to dissect inflamed or scarred tissues without causing trauma or thermal injury.

This technique highlights the principle that in surgery, sometimes simple innovations like a cotton pledget can make complex operations safer and more effective. With careful application, pledget dissection can turn a potentially hazardous procedure into a successful laparoscopic cholecystectomy.