Posterior infundibular dissection: safety first in laparoscopic cholecystectomy

Abstract

Background: Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC. Methods: In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury. Results: Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries. Conclusion: Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.