Acute Cholecystitis Medical Slides

Present the Strasberg Critical View of Safety (CVS) as the gold standard for preventing bile duct injury: Three requirements must be met: (1) hepatocystic triangle cleared of fat and fibrous tissue, (2) lower one-third of gallbladder separated from the liver bed (cystic plate), (3) only two structures (cystic duct and cystic artery) seen entering the gallbladder. Key points: do NOT clip or divide anything until CVS is achieved. If CVS cannot be obtained due to inflammation — use bailout strategies (subtotal cholecystectomy, fundus-first technique, cholecystostomy tube, or open conversion). Bile duct injury rate with CVS: <0.1% vs 0.3-0.5% without.

Present the three grades with management: Grade I (Mild) — no organ dysfunction, no severe local inflammation → early laparoscopic cholecystectomy within 72 hours. Grade II (Moderate) — elevated WBC >18,000, palpable RUQ mass, symptom duration >72 hours, marked local inflammation (gangrenous, pericholecystic abscess, biliary peritonitis) → early cholecystectomy by experienced surgeon, or percutaneous cholecystostomy if high surgical risk. Grade III (Severe) — organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, hematological) → urgent biliary drainage (percutaneous cholecystostomy), cholecystectomy after medical optimization. Early surgery (ideally <24 hours) associated with lower total complications, shorter LOS, and lower costs across all trials.

Present the escalation strategy when CVS cannot be achieved: (1) Stop and consider — call for help, convert to open if necessary (not a failure). (2) Fundus-first (dome-down) technique — starting dissection from fundus toward Hartmann pouch, useful when triangle is frozen. (3) Subtotal cholecystectomy — removal of anterior gallbladder wall leaving posterior wall attached to liver bed, with closure/drainage of Hartmann pouch. RATE trial registry shows this is safe with low bile duct injury rates. (4) Cholecystostomy tube — when cholecystectomy is unsafe, place percutaneous drain, plan interval cholecystectomy. Key teaching point: "the only complication worse than converting to open is a bile duct injury" — the threshold for bailout should be low.