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Resident's Forum |

Raising The Thinker  New Concept for Dissecting the Cystic Pedicle During Laparoscopic Cholecystectomy

Vladimir Neychev, MD, PhD; Pierre F. Saldinger, MD
Arch Surg. 2011;146(12):1441-1444. doi:10.1001/archsurg.2011.572.
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Imprecise dissection due to poor visualization of anatomic structures is among the major causes of biliary injuries during laparoscopic cholecystectomy. Developing new illustrational and rendering techniques represents an important part in decreasing visual deception and subsequent bile duct injuries. We use the model of one of the most well-known pieces of art, Rodin's The Thinker, to visualize the gallbladder and cystic pedicle structures. This minimizes visual deception before dissection, especially in cases with obscured structures. Our method, raising The Thinker, is based on the remarkable similarity between the sculpture and the topographic anatomy of the gallbladder. The method can be used not only for better orientation and visualization during laparoscopic cholecystectomy but also as a tool to complement the teaching of laparoscopic biliary anatomy to surgical residents and medical students.

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Figure 1. Visualizing the gallbladder (GB) as The Thinker. A, Topography of the GB. B, Resemblance between the seated The Thinker and the GB “seated” on top of the common bile duct. C, The fundus of the GB visualized as The Thinker 's head (pink), the body of the GB as the sculpture's torso (dark blue), the infundibulum as the buttocks (green), the neck of the GB as the thigh (yellow), the cystic duct as the leg (purple), the cystic artery as the arm (pale blue), and the common bile duct as the heel (tan). D, The areolar connective tissue plane between the anterior surface of the neck, body of the GB, and cystic artery is visualized as the groin (gray triangular zone).

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Figure 2. Applying the concept during the operation. A, The infundibulum (arrowhead) detached from the common bile duct (CBD) (arrow). B, The window created by a cautery hook in the anterior aspect of the gallbladder (GB) neck (arrowhead). C, The hepatocystic connective tissue (arrowhead) retracting the cystic artery from the neck and cystic duct (black arrow) and the CBD (white arrow). D, The cystic artery (arrowhead), the neck of the GB (black arrow), and the CBD (white arrow).

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Figure 3. Raising The Thinker. A, Risen The Thinker, with an extended arm (cystic artery), thigh (gallbladder [GB] neck), and knee (proximal cystic duct) in resemblance to the GB and the cystic pedicle structures dissected and prepared for clipping. B, The fundus of the GB visualized as the sculpture's head (pink), body of the GB as the sculpture’s torso (dark blue), infundibulum as the buttocks (green), neck of the GB as the thigh (yellow), cystic duct as the leg (purple), common bile duct as the heel (tan), and cystic artery as the arm (light blue).

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