{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,1]],"date-time":"2026-11-01T03:34:07Z","timestamp":1793504047995,"version":"4.5.0"},"reference-count":91,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2023,8,19]],"date-time":"2023-08-19T00:00:00Z","timestamp":1692403200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms \u201ddifficult cholecystectomy\u201d, \u201dbile duct injuries\u201d, \u201dsafe cholecystectomy\u201d, and \u201dlaparoscopy in acute cholecystitis\u201d. The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.<\/jats:p>","DOI":"10.3390\/medicina59081491","type":"journal-article","created":{"date-parts":[[2023,8,21]],"date-time":"2023-08-21T01:33:11Z","timestamp":1692581591000},"page":"1491","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":32,"title":["When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy"],"prefix":"10.3390","volume":"59","author":[{"given":"Catalin","family":"Alius","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1380-2112","authenticated-orcid":false,"given":"Dragos","family":"Serban","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8612-6293","authenticated-orcid":false,"given":"Dan Georgian","family":"Bratu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University \u201cLucian Blaga\u201d, 550169 Sibiu, Romania"},{"name":"Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura Carina","family":"Tribus","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021Bucharest, Romania"},{"name":"Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2133-909X","authenticated-orcid":false,"given":"Geta","family":"Vancea","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Third Clinical Infectious Disease Department, Clinical Hospital of Infectious and Tropical Diseases \u201cDr. Victor Babes\u201d, 030303 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul Lorin","family":"Stoica","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ion","family":"Motofei","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Department of General Surgery, Emergency Clinic Hospital \u201cSf. Pantelimon\u201d Bucharest, 021659 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Corneliu","family":"Tudor","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"},{"name":"Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Crenguta","family":"Serboiu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel Ovidiu","family":"Costea","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania"},{"name":"General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bogdan","family":"Serban","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7474-2395","authenticated-orcid":false,"given":"Ana Maria","family":"Dascalu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ciprian","family":"Tanasescu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University \u201cLucian Blaga\u201d, 550169 Sibiu, Romania"},{"name":"Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bogdan","family":"Geavlete","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bogdan Mihai","family":"Cristea","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,8,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2239","DOI":"10.1007\/s00464-015-4485-2","article-title":"Beyond the learning curve: Incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era","volume":"30","author":"Halbert","year":"2016","journal-title":"Surg. 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