Fat clearance in the hepatocystic triangle during laparoscopic cholecystectomy: Fact or fad? An NIRF-based study

Abstract

Introduction: At present, the pre- and postdissection regions during laparoscopic cholecystectomy (LC) are uniformly described by the term "hepatocystic triangle" (HCT). It is unclear whether a distinction needs to be made. An observational study was undertaken to evaluate the predissection hepatocystic region (pre-HCR) and the postdissection hepatocystic region (post-HCR). Also, the dissection-related changes to the contents of the pre-HCR ("proper HCT") were evaluated.

Methods: A retrospective review of a prospectively maintained database was done. The operative videos of patients who underwent fluorescence-guided surgery from December 2021 to February 2022 were reviewed. Patients with gallstone disease without complications (GSD) were included in the study. Exclusion criteria were acute cholecystitis, choledocholithiasis, biliary pancreatitis, biliary fistulas, and gallbladder wall thickening of ≥3 mm on ultrasonography.

Results: Thirteen patients underwent LC for GSD using standard dissection methods. The boundaries of the pre-HCR were identified before dissection in all patients. The dissection resulted in a quadrangular space lateral to the "proper HCT" in all. The post-HCR contained the undissected "proper-HCT" and the quadrangular space in all. The post-HCR area was 4.4 times that of the pre-HCR (3.2-13.1). The peritoneum over the "proper HCT" was unbreached in all patients, and the target structures were delineated outside of it. A critical view of safety (CVS) was demonstrated outside of the "proper HCT" in all patients.

Conclusion: During near-infrared fluorescence-guided LC for GSD, there is no fat clearance in the "HCT." The hepatocystic region before and at the conclusion were distinctly different. The uniform usage of the term "HCT" does not convey this change.

Keywords: cholecystectomy; gallstones; laparoscopy.