Saudi Journal of Laparoscopy

: 2020  |  Volume : 5  |  Issue : 1  |  Page : 6--11

Cystic duct identification in laparoscopic cholecystectomy review articles

Raafat R Ahmed Alturfi1, Ahmed A Hilmi2,  
1 Department of Digestive Surgery, Gastroenterology and Hepatology Teaching Hospital, Baghdad, Iraq
2 Department of Surgery, Ibn Sina Hospital, Baghdad, Iraq

Correspondence Address:
Dr. Raafat R Ahmed Alturfi
Department of Digestive Surgery, Gastroenterology and Hepatology Teaching Hospital, Baghdad


Postcholecystectomy bile duct injury (BDI) is a life-threatening complication; it associated with increased morbidity and mortality in addition to the medicolegal consequences. The most common cause of serious biliary injury is misidentification of cystic duct-common bile duct relationship. Many techniques had been tested by surgeons to avoid the misidentification injury, this include infundibular technique, critical view of safety, retrograde laparoscopic cholecystectomy, operative cholangiography, fluorescence cholangiography, and biliary navigation surgery using endoscopic nasobiliary drainage. Among these methods, critical view of safety (CVS) has been found most reliable and safe method for cystic duct identification. Moreover, it is easy applicable, fast to learn, and not required special equipment. If the CVS cannot be achieved safely, there are others alternative methods to avoid BDI according to SAGES recommendations.

How to cite this article:
Ahmed Alturfi RR, Hilmi AA. Cystic duct identification in laparoscopic cholecystectomy review articles.Saudi J Laparosc 2020;5:6-11

How to cite this URL:
Ahmed Alturfi RR, Hilmi AA. Cystic duct identification in laparoscopic cholecystectomy review articles. Saudi J Laparosc [serial online] 2020 [cited 2021 Apr 22 ];5:6-11
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Postcholecystectomy bile duct injury (BDI) remains the main concern of the surgeons since the beginning of this procedure in 19th century. The first iatrogenic BDI was described by Sprengel in 1891,[1] not far away from the first planned cholecystectomy in the world which was performed by Langenbuch in 1882.[2] Since that time, the surgeons are continued searching for the best technique to ovoid this catastrophe, but the one which was gained the popular reputation and became the standard of open cholecystectomy is retrograde or fundus first cholecystectomy.

In 1980s, when the era of laparoscopic cholecystectomy (LC) began, and in spite of major advantages of this procedure (less pain, sick leave wound complications, and more cosmetic), surgeons disappointed by the increase in BDI 4–6 times over the open method.

Early series of LC reported that the incidence of major complications ranging from 5.4% to 13.6%. These problems included hemorrhage, wound infection, trocar, and Veress needle injuries. However, the major bile BDI is the most dramatic (and at the same time can be preventable complication) account between 0.15% and 0.6%.[3],[4],[5],[6]

Italian National Study included 56591 LCs found that overall incidence of BDIs is 0.42%. These include major injuries involving the common bile duct (CBD), main biliary confluence, or main bile ducts which are account 75.7%. While minor injuries involving the cystic duct or small peripheral or Luschka ducts, are account 24.3%.[7]

MacFadyen et al. review article from 1991 to 1995 including 114005 patients with LC and found that the incidence of BDI is 0.5% and bile leak is 0.38%.[8] The most common cause of serious biliary injury is misidentification, usually accounts 75% of causes of BDI. While technical faults account about 25% only, these include improper use of monopolar coagulation, an unspecified technical mistake, and a problem during the control of intraoperative hemorrhage.[8]

Regarding misidentification, the CBD is mistaken to be the cystic duct and less commonly, an aberrant duct is misidentified as the cystic duct. The former was called as the classical injury.[9]

In this current situation and as in old days, surgeons are testing many methods for proper identification of cystic duct and trying to avoid CBD injury.

The aim of this article to is to review recent techniques of the identification of cystic duct during LC and to focus on two most commonly used technique and to choose the safest method for prevention of BDI.


An article search was performed in PubMed and Google scholar using multiple titles that related to LC as well as terms that link to preventions of biliary injury and identification or misidentification of cystic duct. Articles contain cross-referenced terms like: technique and dissection of “Calot's triangle” “hepatocystic triangle” also included. A further literature search was performed using terms related to the different techniques of the bile ducts identification such as infundibular technique, critical view of safety, retrograde LC, operative cholangiography, fluorescence cholangiography, and biliary navigation surgery using endoscopic nasobiliary drainage (ENBD). All these articles are reviewed for the details of the technique and comparisons with other methods.


The following are the most common methods which are used for cystic duct identification and prevention of BDI.

Infundibular technique

In this method, the duct connected to infundibulum which is thought to be the cystic duct, is isolated by dissection of the Calot's triangle and once isolated, it clipped and divided. The definitive identification is concluded (but not approved) as a result of seeing funnel shape of the cystic duct widens to become the gallbladder infundibulum. This technique is the first and still the most common method of LC because it fast and easy to learn as it not required complete dissection of hepatocystic triangle. The infundibular technique was the traditional method teaching in training centers in the past and one found in the early publications describing the technique of LC.[10],[11]

Retrograde laparoscopic cholecystectomy (Fundus down)

This method was introduced to imitate open fundus- first cholecystectomy; the procedure involves incision of the visceral peritoneum from the infundibulum away from Calot's triangle along the gallbladder bed up to the fundus; then the dissection continues from the fundus down to the infundibulum. In this way, the gallbladder is left attached by the cystic artery and cystic duct only, which can be clipped and divided in turn.[12],[13] Some surgeons do this method as standard procedure for every case,[9] others performed it in case they could not achieve critical view of safety (CVS) safely.[14]

Intra-operative cholangiography

Despite of many studies on the association between intraoperative cholangiography (IOC) and the prevention of BDI, the results of population-based studies using administrative and hospital data are conflicting.[15] Systematic reviews of randomized controlled trials published in 2012 failed to demonstrate evidence to support the routine use of IOC would prevent BDI.[16] However, when the anatomic orientation of hepatocystic triangle became uncertain during laparoscopy, many surgeons promptly performed IOC to reestablish the orientation of Calot's triangle and avoid biliary tract injury (safety triangle).[17]

Fluorescence cholangiography (near-infrared fluorescence cholangiography

It is a real-time, radiation-free method to enhance the visualization of the biliary tree anatomy. All patients received a dose of 2.5 mg of ICG 45 min prior to the beginning of the surgical procedure, using a laparoscopic NIRF imaging system (Karl Storz GmbH, Tuttlingen, Germany). During dissection of the base of the gallbladder and the cystic duct and the extrahepatic bile, ducts were visualized using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. However, near-infrared fluorescence cholangiography remains an investigational technique that might prove to be beneficial in the future. The current level of evidence in published studies is low and well-designed prospective trials should be encourage.[15]

Critical view of safety

In 1995, a method of identification of the cystic structures was introduced by Steven Strasberg, referred to as the CVS.[18] During the past 25 years, this method was adopted by many surgeons around the world. The study done in a single surgical unit using the “critical view of safety” technique, found that there was no single major BDI in 1046 cholecystectomies done.[19]

The purpose of this article is to understand why this method is protective against misidentification.

Exposing common hepatic duct

The procedure is slightly modified by that; the cystic artery and cystic duct were ligated with clips only after the cystic duct, the CBD, and the common hepatic duct (CHD) were clearly identified either using suction and irrigation tube for blunt dissection by flushing and aspiration to expose the Calot's triangle,[20] or mono polar hook electrode instrument.[21]

Biliary navigation surgery using endoscopic nasobiliary drainage tube

Some surgeons test biliary navigation surgery using ENBD tube to avoid BDI during LC. The benefit of IOC using an ENBD tube is that the identification of the anatomical relationship between the cystic duct and CBD can be confirmed using IOC through the ENBD tube.[22] However, Noji et al. found that adding additional procedure without significant difference between ENBD-assisted LC and standard LC regarding BDI, operations time, and conversion to laparotomy, but it may reduce incidence of BDI in case of biliary anomaly.[23]


BDI is a life-threatening complication, it associated with increased morbidity and mortality of the patient as well as risking the reputation of the surgeon, in addition to the medicolegal consequences. Researchers have analyzed the problem of postcholecystectomy BDI, and have founded that BDI results from misidentification of the cystic structures at the Calot's triangle.[9],[18] The surgeon should discriminate between 2 anatomical areas to avoid this injury. The Calot's triangle; which is bounded by the cystic duct inferiorly, the CHD medially, and the cystic artery superiorly. While the hepatocystic triangle, the hepatic component referring to the undersurface of the liver, is replaces the cystic artery as the superior border of this space [Figure 1].[24]{Figure 1}

Regarding the “infundibular method” [Figure 2], it involves dissection of the Calot's triangle only, and does not involve too much dissection, so that the cystic duct is identified by seeing a structure that enters the GB. However, in some instances, like in severe acute or chronic cholecystitis, there will be too much adhesions between the GB side wall and the surrounding structures, so there will be obliteration of the triangle of Calot, which results in a false-funnel view, so that at the end of dissection, we will see the same structure but it is the CBD and not cystic duct. Furthermore, the way of traction of the gallbladder may affect the identification of the cystic structures.[25]{Figure 2}

While in the CVS [Figure 3], there should be complete removal and clearing of fibrofatty and areolar tissue in the hepatocystic triangle, and freeing of the lower 1–3 cm of the GB from the cystic plate (the hepatic bed of the gallbladder), so that at the end of the dissection, there are two and only two structures seen entering the GB, the cystic duct and cystic artery.[7],[8],[19] This method has now become part of the culture of safety in performing LC according to SAGES.[25]{Figure 3}

In an observational prospective study, that was done in Basrah medical institution, by Mohamed Shaheed and colleagues, 250 cases of lap. Cholecystectomy using CVS were compared with 250 cases of lap. Cholecystectomy using CVS were compared with 250 cases of laparoscopic Cholecystectomy using infundibular method in the period between 2009 and 2013. The incidence of B.D. I was 1.6% in the infundibular method group, while in the CVS group, it was 0% which was statistically significant, (P > 0.05).[26],[27]

Factors obscuring the cystic duct

There are a number of factors that result in hiding of the cystic duct, and surgeon consider the CBD as cystic duct. These include the direction of traction of the GB, inflammatory adhesions, and bands between CBD and the GB, Mirrizzi's syndrome, increased thickness of the GB wall, and distention of the GB which results in difficult handling and improper traction. This is called by Strasberg as the hidden cystic duct syndrome.[10]

What make things worse some surgeons use 3-port technique in LC. The traction of the GB in case of 3-port technique is cephalic direction, rather than a downward and lateral direction which will result in that the cystic duct and the CBD will be seen in one line which make the misidentification injury more vulnerable.

Critical view of safety in severe inflammation

In cases of mild-to-moderate inflammation of the GB, then cholecystectomy will be straight-forwards. In conditions, were there is severe acute or chronic inflammation, the cystic duct will be hidden by the inflammatory process, in addition to the adhesions between the side of the GB and the CHD, resulting in that the CBD will be dissected and isolated in the belief that it is the cystic duct. If we are using the infundibular method of identification, then the CBD will be clipped and divided as a result of the false funnel view and visual deception.[10] In the CVS technique, the CBD might be inadvertently dissected and isolated, but should not ligated or divided, because the other requirements of the CVS are not achieved, until the hepatocystic triangle is fully dissected, and the lower part of the GB is separated from its hepatic bed. According to SAGES Safe Cholecystectomy Program; if there is a problem in proceeding with the dissection, or if it take a long time to achieve the critical view, the surgeon at this point should think of a solution other than the attaining the critical view to solve the problem, such as calling for the help of a more experienced nearby surgeon, conversion to open cholecystectomy, doing IOC, or to perform partial (subtotal) cholecystectomy.[26],[28],[29]

How to achieve a safe critical view of safety

Under general anesthesia, with endotracheal intubation, pneumoperitoneum is created by a CO2 source connected to a 10 mm supraumbilical port inserted by open method (rather than the closed method using Vere's needle). Another 10 mm port is inserted in the epigastrium slightly to the right of the midline and below the xiphisternum. Then, two 5 mm ports are inserted in the right hypochondrium at the anterior and mid-axillary lines respectively at appropriate distance from the GB. The camera is introduced through the supraumbilical port and is used for inspection of the abdominal cavity and the insertion of the ports under direct vision.

The GB is identified, retracted from its fundus by a noncrushing forceps upwards towards the diaphragm. The infundibulum of the GB is also grasped by a grasper and retracted medially and upwards to inspect the hepatocystic triangle posteriorly, and downward and laterally to inspect the triangle anteriorly. The dissection of hepatocystic triangle should start posteriorly because there is less inflammation and adhesions, and to be away from the danger zone.

Initially, the lower 1/3 of the GB is separated from the cystic plate (hepatic bed). After that all fatty and areolar tissues are dissected and removed to clear the hepatocystic triangle. The direction of traction of the GB described earlier is to ensure that the cystic duct is not in a direct line with the CBD.

The cystic duct and artery are now skeletonized and come into view, and the hepatocystic triangle is turned into a quadrangle [Figure 4], in order to keep the GB away from the CBD. This also clearly identify the looped the right hepatic artery which called “Caterpillar turne” or “Moynihan's hump” that it may be mistaken for the cystic artery, making it prone to injury during the procedure [Figure 5]. Moreover, injury to the aberrant right posterior hepatic duct is also can be avoided by this dissection [Figure 6].{Figure 4}{Figure 5}{Figure 6}

The cystic artery is ligated first by 2 proximal clips and one distal, and cut in between by scissors. No diathermy should be used to cut the artery, this may result in a condition known as the pseudoaneurism of the cystic artery.[30]

The cystic duct is then ligated by two proximal and one distal clips and is cut in between by scissors. The cystic artery is dissected before the duct because it will provide a wider space for identification of the duct, and to reduce the tension on the duct, hence to avoid the tenting effect on the CBD. Moreover, if the cystic duct is ligated before the artery, this may cause tension and eventually avulsion of the artery and bleeding. Complete separation of the posterior wall of the GB from liver done by monopolar diathermy leaving the cystic plate intact to minimize bleeding. The GB is withdrawn out usually through the 10 mm epigastric port. Inspection of the hepatic bed with irrigation and suction is done, and any bleeding points are dealt with by diathermy.

The final inspection of the peritoneal cavity is done, the ports are withdrawn under direct vision, the camera is withdrawn and the wounds are closed. No drain is deployed except in few instances such as partial cholecystectomy where the cystic duct cannot be ligated.

Hence, in summary, our plan to achieve a safe CVS is:

Inspection before dissectionPosterior dissection before anteriorCystic plate separation before hepatocystic triangle clearanceCystic artery ligation before cystic duct.


Major BDI can be avoided in most of the cases if the surgeon considered cholecystectomy as a practice of anatomy rather than removing gallbladder. There is no single GB similar to each other and surgeons should have thorough knowledge about different anatomical variation to avoid catastrophe of biliary injury. Among different technique of proper cystic duct identification, this review recommend CVS to be used, because it most reliable, safe, easy applicable, fast to learn, and not required special equipment.

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Conflicts of interest

There are no conflicts of interest.


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