Modified Fundus First Technique for Laparoscopic Cholecystectomy

Modified Fundus First LC

Abstract

Laparoscopic cholecystectomy (LC) is the standard treatment for gallstone disease and acute cholecystitis. However, bile duct and vascular injuries remain serious complications, particularly in patients with severe inflammation, dense adhesions or anatomical variations; wherein, obtaining the critical view of safety (CVS) can be challenging. Hence, the fundus-first technique is commonly employed as a bailout strategy in difficult cases; nevertheless, severe injuries have been reported due to dissection in incorrect planes and excessive proximity to the hepatic hilum.
This article introduces the concept of a modified fundus-first technique. It combines limited dissection of the hepatocystic triangle, so as to establish safe anatomical reference points with controlled fundus-down gallbladder dissection along the appropriate surgical plane. This approach aims to enhance procedural safety in cases where conventional infundibular dissection is not feasible. Additionally, key anatomical landmarks, limitations of the CVS, and important technical precautions are reviewed to provide practical guidance for minimizing the risk of bile duct injury during LC.