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The Calot’s Triangle in Laparascopic Cholecystectomy

Laparascopic cholecystectomy requires proper knowledge of anatomical landmarks such as the Calot's Triangle. Hira Hussain Khan discusses the miracles of this triangle beyond a favorite quiz question...


Laparascopic Cholecystectomy

Laparascopic cholecystectomy requires adequate knowledge of important anatomical landmarks

Safety of any surgical procedure lies in the proper identification of the targeted anatomical structure. General surgeons’ ever favorite and cherished question projected on the medical students during their rotations is regarding Calot’s Triangle and especially, when it comes down to its boundaries, one needs to be specific and better not slip around because you might end up damaging important vessels. Calot’s triangle holds its utmost importance in surgical procedure of Laparoscopic Cholecstetomy. It is a less invasive surgical procedure for gall bladder removal, with better recovery in which several small incisions rather than a one large incision are made comparatively to open laparoscopy.

Cholecystectomy is defined as surgical removal of gall bladder. Indications of gall bladder removal include symptomatic gall stones or any underlying gall bladder pathology. Two surgical methods for this very purpose are laparoscopic cholecystectomy and open cholecystectomy. The latter one is becoming obsolete since it requires a wider exposure through the surgical incison and post-operatively patients are prone to development of infections. Laparoscopic cholecystectomy is gaining phenomenal  acceptance, being a standard and preferable approach. The challenging aspect of this surgery is safeguarding the structures forming boundaries of Calot’s triangle and then carrying out safe dissection of its contents.

The Calot’s triangle, also known as cysto hepatic triangle or the hepatobiliary triangle,  is an anatomic space bordered by the common hepatic duct medially, the cystic duct laterally and the cystic artery (liver) superiorly.

The safe and sound dissection or removal of the gall bladder via portals away from the liver bed, assisted by video camera placed in abdominal cavity can only be made possible by meticulous identification of the Calot’s triangle boundaries. The cystic artery which courses through the triangle must be avoided any insult and properly identified by the surgeon. After appraising the Calot’s triangle, cystic duct and cystic artery are separated and carefully clipped using titanium clips by the surgeon.

Highlights about proper exposure of Calot’s triangle via laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot’s Triangle.

The most remarkable injury during surgical procedure of laparoscopic cholecystectomy is to common bile duct which connects cystic and common hepatic duct to duodenum. The bile leakage due to injury potentially causes serious infections. Minor injury cases are dealt non surgically whereas major injuries require strong corrective surgery assisted by a biliary surgeon.

An error in the proper identification of structures and an accidental damage especially to common bile duct is unacceptable. It casts negative shadow on surgeon’s competitiveness and put serious consequences on the patient. You will be surprised to know this fact that most leading lawsuit in the developed world of medical malpractice filed against surgeons is common bile duct injury during laparoscopic cholecystectomy. That is why a pressing stress is laid upon the acknowledgment of Calot’s triangle.

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