This video explains in detail the surgical approach to Laparoscopic Cholecystectomy in Acute Cholecystitis, focusing on the technique of cystic duct ligation and the importance of achieving the Critical View of Safety (CVS). The lecture covers operative steps, anatomical landmarks, safety principles, and strategies to prevent bile duct injury during difficult gallbladder surgeries. This educational lecture is especially useful for surgeons, laparoscopic trainees, and medical students seeking a clear understanding of safe cholecystectomy practices in acute inflammation.

Acute cholecystitis is a common surgical emergency caused most often by gallstone obstruction of the cystic duct, leading to gallbladder inflammation. With advances in minimally invasive surgery, laparoscopic cholecystectomy has become the gold standard treatment, even in acute settings. However, inflammation, edema, and distorted anatomy in acute cholecystitis increase the risk of bile duct injury. Proper cystic duct ligation and strict adherence to the Critical View of Safety (CVS) are essential to ensure safe outcomes.

Pathophysiology of Acute Cholecystitis

Acute cholecystitis occurs due to prolonged cystic duct obstruction, resulting in gallbladder distension, ischemia, and bacterial infection. The inflammatory process causes tissue friability, adhesions, and anatomical distortion in Calot’s triangle, making laparoscopic dissection more challenging.

Role of Laparoscopic Cholecystectomy

Early laparoscopic cholecystectomy (within 72 hours of symptom onset) is widely recommended as it reduces hospital stay, complications, and recurrence of symptoms. Despite technical difficulty, experienced surgeons can safely perform the procedure using meticulous dissection techniques and standardized safety principles.

Surgical Challenges in Acute Cholecystitis

• Edematous and thickened gallbladder wall

• Dense adhesions in Calot’s triangle

• Increased bleeding due to inflammation

• Difficulty in identifying cystic duct and artery

• Higher risk of bile duct injury

These challenges necessitate a cautious, stepwise surgical approach.

Technique of Cystic Duct Ligation

Proper identification and secure ligation of the cystic duct are critical steps in laparoscopic cholecystectomy.

Key principles include:

• Gentle traction on the gallbladder fundus and infundibulum

• Careful dissection close to the gallbladder wall

• Skeletonization of the cystic duct before ligation

• Use of clips, endoloop, or intracorporeal suturing depending on duct thickness

• Avoidance of blind clipping in inflamed tissue

In cases of severe inflammation or a wide cystic duct, an endoloop or suturing provides safer control than standard clips.

Critical View of Safety (CVS)

The Critical View of Safety, introduced by Strasberg, is the most effective method to prevent bile duct injuries.

To achieve CVS, three criteria must be fulfilled:

1. The hepatocystic triangle is cleared of all fat and fibrous tissue

2. The lower one-third of the gallbladder is separated from the liver bed

3. Only two structures (cystic duct and cystic artery) are seen entering the gallbladder

No structure should be clipped or divided until all three criteria are clearly met.

Strategies When CVS Cannot Be Achieved

In difficult cases of acute cholecystitis, alternative strategies should be considered:

• Fundus-first (top-down) dissection

• Subtotal cholecystectomy

• Conversion to open surgery

• Placement of a drain and delayed intervention

These options reflect sound surgical judgment and prioritize patient safety over procedural completion.

Postoperative Outcomes and Complications

When performed using proper technique and CVS principles, laparoscopic cholecystectomy in acute cholecystitis has outcomes comparable to elective surgery. Potential complications include bile leak, bleeding, infection, and rarely bile duct injury. Early recognition and management are essential.

Conclusion

Laparoscopic cholecystectomy in acute cholecystitis is safe and effective in experienced hands. The cornerstone of safety lies in meticulous dissection, secure cystic duct ligation, and unwavering adherence to the Critical View of Safety. Surgeons must remain flexible in their approach and adopt alternative strategies when anatomy is unclear, ensuring optimal patient outcomes and minimizing complications.