The evaluation of B-SAFE and ultrasonographic landmarks in safe orientation during laparoscopic cholecystectomy

Introduction
Even though the prevalence of bile duct injury (BDI) is nowadays lower than before and close to the era of open cholecystectomy, there is a strong need to make it even lower. B-SAFE is a group of five visual landmarks that may be used before dissection in the hepatocystic triangle for better orientation around the gallbladder. Another method is laparoscopic ultrasound (LUS), which enables confirmation of structures in the hepatoduodenal ligament and delineation of the safe plane of dissection.

Aim
To evaluate the use of B-SAFE and ultrasonographic landmarks during laparoscopic cholecystectomy in navigation around the gallbladder.

Material and methods
The study group consisted of 158 patients with symptomatic cholecystolithiasis. The methods of intraoperative orientation around the gallbladder attempted in every patient during laparoscopic cholecystectomy included B-SAFE and ultrasonographic landmarks.

Results
The identification rate of ultrasonographic landmarks – the upper border of “Mickey Mouse” sign (MMS) (the equivalent of the Rouviere’s sulcus), the bile duct, and the hepatic artery – was significantly higher in patients with body mass index ≥ 30 kg/m2 and fibrosis and chronic inflammation in the gallbladder neck than B-SAFE. LUS was also significantly more successful in the identification of the bile duct in the whole study group than B-SAFE. There were no significant differences according to the identification of the duodenum. The conversion rate was 2.6%, and we did not observe any BDI.

Conclusions
Visual landmarks defined in B-SAFE are not as reliable as ultrasonographic landmarks; thus, LUS should be taken into consideration in the first place as a method of navigation around the gallbladder.