{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T19:30:43Z","timestamp":1786649443736,"version":"build-2736575974"},"reference-count":14,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"Abstract<\/jats:title>\n \n Introduction:<\/jats:title>\n Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstone disease. Achieving the critical view of safety (CVS) \u2013 clearing the hepatocystic triangle, freeing the gall bladder\u2019s lower third and identifying only the cystic duct and artery \u2013 is essential to prevent vasculobiliary injury. The guidelines advocate CVS but do not specify where to initiate dissection. We compared two dissection strategies.<\/jats:p>\n <\/jats:sec>\n \n Patients and Methods:<\/jats:title>\n \n We retrospectively analysed 350 consecutive laparoscopic cholecystectomies for acute cholecystitis (2020\u20132021 and 2024\u20132025) performed by two surgeons at community hospitals. In Method 1,\n n<\/jats:italic>\n = 100, the lower third of the gall bladder was mobilised before dissecting Calot\u2019s triangle; in Method 2,\n n<\/jats:italic>\n = 150, the triangle was dissected first and the lower gall bladder was then mobilised. Cases with severely inflamed or \u2018frozen\u2019 anatomy were treated with domedown or subtotal cholecystectomy (Method 3 salvage\/bailout,\n n<\/jats:italic>\n = 100). The outcomes included attainment of CVS, bile duct injury (BDI) and post-operative bile leak.\n <\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n CVS was documented in all Method 1 and Method 2 procedures, but not in the salvage group. No BDIs occurred. Post-operative bile leak rates were 2% for Methods 1 and 2 and 9% for Method 3; all salvage cases had intraoperative spillage and 3% required conversion to open surgery. Differences in leakage between the two planned techniques were not statistically significant.<\/jats:p>\n <\/jats:sec>\n \n Conclusions:<\/jats:title>\n Both lower-end-first and Calot\u2019s triangle-first dissection strategies reliably achieve the critical view and allow the safe completion of LC. When inflammation prevents these approaches, domedown or subtotal cholecystectomy provides a safe bailout, with no BDI risk.<\/jats:p>\n <\/jats:sec>","DOI":"10.4103\/jmas.jmas_321_25","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T08:02:45Z","timestamp":1776067365000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Initiating dissection to achieve the critical view of safety in minimally invasive cholecystectomy: A retrospective comparison of lower-end-first, Calot\u2019s triangle-first and salvage approaches"],"prefix":"10.4103","author":[{"given":"Anupam Kumar","family":"Gupta","sequence":"first","affiliation":[{"name":"Department of General Surgery, Jackson North Medical Center, Miami, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,4,13]]},"reference":[{"key":"R1-20260413","first-page":"e\u21c2","article-title":"Laparoscopic approach for gallstone ileus in geriatric patients","volume":"12","author":"Gupta","year":"2020","journal-title":"Cureus"},{"key":"R2-20260413","doi-asserted-by":"crossref","first-page":"e157","DOI":"10.1055\/s-0042-1744154","article-title":"Critical view of safety in laparoscopic cholecystectomy:A word of caution in cases of aberrant anatomy","volume":"8","author":"Antonopoulou","year":"2022","journal-title":"Surg J (N Y)"},{"key":"R3-20260413","doi-asserted-by":"crossref","first-page":"3609","DOI":"10.1007\/s00464-024-10873-0","article-title":"Video-Based Surgical Quality Assessment Collaborators. Surgical quality assessment of critical view of safety in 283 laparoscopic cholecystectomy videos by surgical residents and surgeons","volume":"38","author":"Gr\u00fcter","year":"2024","journal-title":"Surg Endosc"},{"key":"R4-20260413","doi-asserted-by":"crossref","first-page":"201","DOI":"10.14701\/ahbps.22-064","article-title":"How to achieve the critical view of safety for safe laparoscopic cholecystectomy:Technical aspects","volume":"27","author":"Gupta","year":"2023","journal-title":"Ann Hepatobiliary Pancreat Surg"},{"key":"R5-20260413","first-page":"e10817","article-title":"A retrospective Study comparing radiological to histopathological diagnosis after laparoscopic cholecystectomy for suspected cholecystitis","volume":"12","author":"Gupta","year":"2020","journal-title":"Cureus"},{"key":"R6-20260413","doi-asserted-by":"crossref","first-page":"689","DOI":"10.1097\/00000658-199611000-00019","article-title":"Laparoscopic cholecystectomy is the current \u201cgold standard\u201cfor the treatment of gallstone disease","volume":"224","author":"Sain","year":"1996","journal-title":"Ann Surg"},{"key":"R7-20260413","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.4240\/wjgs.v16.i4.1130","article-title":"Burden of gallstone disease in the United States population:Prepandemic rates and trends","volume":"16","author":"Unalp-Arida","year":"2024","journal-title":"World J Gastrointest Surg"},{"key":"R8-20260413","doi-asserted-by":"crossref","first-page":"3","DOI":"10.21037\/tgh-23-56","article-title":"Laparoscopic versus robotic cholecystectomy:A systematic review with meta-analysis to differentiate between postoperative outcomes and cost-effectiveness","volume":"9","author":"Singh","year":"2024","journal-title":"Transl Gastroenterol Hepatol"},{"key":"R9-20260413","first-page":"e10630","article-title":"The role of minimally invasive surgery in appendectomy within a hernia","volume":"12","author":"Gupta","year":"2020","journal-title":"Cureus"},{"key":"R10-20260413","doi-asserted-by":"crossref","first-page":"e2016.00065","DOI":"10.4293\/JSLS.2016.00065","article-title":"Risk factors for difficult laparoscopic cholecystectomy in acute cholecystitis","volume":"20","author":"Hayama","year":"2016","journal-title":"JSLS"},{"key":"R11-20260413","first-page":"e8919","article-title":"Bleeding after a single dose of ketorolac in a postoperative patient","volume":"12","author":"Gupta","year":"2020","journal-title":"Cureus"},{"key":"R12-20260413","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1007\/s00268-015-3365-1","article-title":"Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population-based case-control study","volume":"40","author":"T\u00f6rnqvist","year":"2016","journal-title":"World J Surg"},{"key":"R13-20260413","doi-asserted-by":"crossref","first-page":"1142579","DOI":"10.3389\/fsurg.2023.1142579","article-title":"State of the art in subtotal cholecystectomy:An overview","volume":"10","author":"Ram\u00edrez-Giraldo","year":"2023","journal-title":"Front Surg"},{"key":"R14-20260413","doi-asserted-by":"crossref","first-page":"273","DOI":"10.4103\/jmas.JMAS_268_16","article-title":"Clinical reappraisal of vasculobiliary anatomy relevant to laparoscopic cholecystectomy","volume":"13","author":"Singh","year":"2017","journal-title":"J Minim Access Surg"}],"container-title":["Journal of Minimal Access Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.4103\/jmas.jmas_321_25","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T18:54:15Z","timestamp":1786647255000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.4103\/jmas.jmas_321_25"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,13]]},"references-count":14,"URL":"https:\/\/doi.org\/10.4103\/jmas.jmas_321_25","relation":{},"ISSN":["0972-9941","1998-3921"],"issn-type":[{"value":"0972-9941","type":"print"},{"value":"1998-3921","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,13]]},"assertion":[{"value":"2025-07-26","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-10-13","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}