{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T13:02:59Z","timestamp":1769000579991,"version":"3.49.0"},"reference-count":17,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2019,11,11]],"date-time":"2019-11-11T00:00:00Z","timestamp":1573430400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Annals of Gastroent Surgery"],"published-print":{"date-parts":[[2020,3]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D\u2010line) as a feasible landmark for carrying out difficult LC. The D\u2010line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D\u2010line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty\u2010two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D\u2010line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D\u2010line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54\u2010290) min and 10 (range, 0\u2010100) mL, respectively. No intra\u2010 or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.<\/jats:p>","DOI":"10.1002\/ags3.12297","type":"journal-article","created":{"date-parts":[[2019,11,11]],"date-time":"2019-11-11T11:07:10Z","timestamp":1573470430000},"page":"170-174","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Segment IV approach for difficult laparoscopic cholecystectomy"],"prefix":"10.1002","volume":"4","author":[{"given":"Hiroaki","family":"Kitamura","sequence":"first","affiliation":[{"name":"Department of Surgery The Jikei University Kashiwa Hospital Chiba Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6388-0717","authenticated-orcid":false,"given":"Shuichi","family":"Fujioka","sequence":"additional","affiliation":[{"name":"Department of Surgery The Jikei University 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