Critical Line of Safety Guided Decision Making for Laparoscopic Subtotal Cholecystectomy in Difficult Gallbladder Surgery

Application of Critical Line of Safety in Difficult Gallbladders

Abstract

Objective: This article proposes incorporating the critical line of safety (CLS) as an anatomical and decision-making landmark to guide a safe laparoscopic cholecystectomy (LC); especially when critical view of safety (CVS) cannot be achieved.
Material and Methods: The CLS is defined as the caudocranial line running along the lateral edge of the hepatoduodenal ligament that extends from the duodenum to the cystic-hilar plate junction. Two key rules are emphasized: (1) no structure medial to the CLS should be divided and (2) dissection beyond the CLS should be avoided or performed with awareness of potential thermal injury. If completing total cholecystectomy requires resection beyond the CLS, this represents the “inflection point” to stop and perform a laparoscopic subtotal cholecystectomy.
Results: In difficult cholecystectomy, the key decision is to stop before bile duct injury (BDI) occurs. In cases of unattainable CVS, the CLS helps the surgeon identify the extrahepatic bile duct and thereby facilitates safe dissection. When difficult anatomy is combined with failure to achieve CVS, CLS-guided decision-making provides a foundation basis for the surgeon to recognize the inflection point and stop attempting total cholecystectomy.
Conclusion: CLS-guided decision-making provides an objective and anatomical reference for identifying the safe limit of dissection and determining when to terminate attempts at total cholecystectomy. Incorporating this landmark into standard practice may enhance surgical awareness, reduce perception bias, and prevent BDI. Further clinical validation is warranted to establish the role of CLS in safe LC.