title: Protocol for laparoscopic cholecystectomy: Is it rocket science?
abstract: Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot's triangle clearance in the overhead view; (5) Calot's triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot's triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Tomohide
authors.initials: T
authors.lastname: Hori
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Fumitaka
authors.initials: F
authors.lastname: Oike
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Furuyama
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Takafumi
authors.initials: T
authors.lastname: Machimoto
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Kadokawa
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Hata
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Shigeru
authors.initials: S
authors.lastname: Kato
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Daiki
authors.initials: D
authors.lastname: Yasukawa
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Yuki
authors.initials: Y
authors.lastname: Aisu
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Maho
authors.initials: M
authors.lastname: Sasaki
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Kimura
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Yuichiro
authors.initials: Y
authors.lastname: Takamatsu
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Naito
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Masaya
authors.initials: M
authors.lastname: Nakauchi
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Tanaka
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Daigo
authors.initials: D
authors.lastname: Gunji
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Kiyokuni
authors.initials: K
authors.lastname: Nakamura
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Kiyoko
authors.initials: K
authors.lastname: Sato
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Mizuno
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Taku
authors.initials: T
authors.lastname: Iida
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Shintaro
authors.initials: S
authors.lastname: Yagi
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Uemoto
authors.affiliation: Tomohide Hori, Hiroaki Furuyama, Takafumi Machimoto, Yoshio Kadokawa, Toshiyuki Hata, Shigeru Kato, Daiki Yasukawa, Yuki Aisu, Maho Sasaki, Yusuke Kimura, Yuichiro Takamatsu, Tsunehiro Yoshimura, Department of Gastrointestinal and General Surgery, Tenriyorodusoudanjyo Hospital, Tenri 632-8552, Japan.
authors.forename: Tsunehiro
authors.initials: T
authors.lastname: Yoshimura
mesh_terms: D001660:Biliary Tract Diseases / Q000209:etiology; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D002983:Clinical Competence; D002985:Clinical Protocols; D017558:Elective Surgical Procedures; D006801:Humans; D059032:Learning Curve; D061214:Patient Safety; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Biliary injury; Critical view of safety; Gallbladder; Laparoscopic cholecystectomy; Protocol