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PURPOSE: To audit our experience with a dome down technique for laparoscopic cholecystectomy (DDLC) regarding clinical outcomes, safety, and demonstration of the critical view of safety (CVS).

METHODS: We reviewed a prospectively collected data set of all patients who underwent cholecystectomy(CCY) from 2000 through 2010 by a single surgeon. All patients were planned for primary DDLC and transection of the cystic artery with a Harmonic Scalpel. Electronic records were queried for additional data.

RESULTS: 715 consecutive patients (72% female) underwent CCY; 581(74%) elective, 134(26%) acute. One(0.14%) required conversion to open CCY; all others underwent DDLC. Five (0.69%) had minor complications: ileus in 2 cases, trocar site hernia in 1. Biloma was found in 2 patients however there were no bile duct injuries or biliary strictures on subsequent evaluation. A single enterotomy occurred during Hasson canula placement in a patient with extensive adhesions; this led to the sole conversion to open CCY. Estimated blood loss was minimal in all cases. Most patients(84%) were discharged on the day of surgery. Length of stay and complication rate did not vary between patients who had acute or elective indications for surgery. The CVS was identified in all (566) patients since 2001, when we began documenting identification or non-identification of the CVS. In cases for which precise operative times were available, DDLC averaged 37 minutes. Intra-operative cholangiogram (IOC) was never needed to clarify the anatomy in Calot’s triangle. Planned IOC was performed in 58 cases(8.1%): 34 for gallstone pancreatitis, 10 for choledocolithiasis, 9 for biliary colic, 3 for cholangitis, and 1 for primary biliary sclerosis.

CONCLUSIONS: This 10 year, single-operator experience demonstrates that DDLC is a safe and practical approach to CCY in a diverse group of patients and can be used as a primary approach to laparoscopic cholecystectomy (LC) with a low complication rate. We hypothesize that because this approach requires circumferential visualization of the contents of Calot’s triangle, the CVS is readily identified in all cases. Improved visualization enhances the safety of this approach and has caused some to advocate DDLC as a way to avoid conversion to open CCY in patients with “difficult gallbladders”. We posit that the high rate of bile duct injuries associated with the dawn of laparoscopy, may have been a byproduct of the shift from dome-down to bottom-up infundibular dissection rather than the shift from open to laparoscopic techniques, per se. While we acknowledge that experienced surgeons should continue to use techniques with which they have experienced success, we propose a greater role for DDLC as an initial approach to LC in surgical training, to demonstrate the CVS and to allow a safe laparoscopic cholecystectomy in all circumstances.

The Critical View of Safety in Dome Down Laparoscopic Cholecystectomy: (A) cystic artery (B) cystic duct (C) common bile duct (D) infundibulum of gallbladder (E) gallbladder fossa.