Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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VOLUME 11 , ISSUE 3 ( September-December, 2022 ) > List of Articles

INVITED ARTICLE

Tips and Tricks to Avoiding Iatrogenic Bile Duct Injuries during Cholecystectomy

Chance Nichols, Joshua Dilday, Matthew Martin

Keywords : Bailout procedures, Bile duct injury, Cholangiography, Cholecystitis, Critical view of safety, Subtotal cholecystectomy

Citation Information : Nichols C, Dilday J, Martin M. Tips and Tricks to Avoiding Iatrogenic Bile Duct Injuries during Cholecystectomy. Panam J Trauma Crit Care Emerg Surg 2022; 11 (3):123-133.

DOI: 10.5005/jp-journals-10030-1406

License: CC BY-NC 4.0

Published Online: 31-12-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Aim: The aim of this article was to assess the currently available literature and provide a review of strategies and techniques for surgeons performing laparoscopic cholecystectomy (LC) to minimize the risk of bile duct injury (BDI). Background: Laparoscopic cholecystectomy (LC) is one of the most common general surgical procedures performed worldwide, with BDI being the most dreaded complication. Recently, the concept of a universal culture of safety for performing LC has introduced strategies to mitigate the risk and enhance the prevention of BDI. Review results: The first concept to performing safe LC and minimizing the risk of BDI is the recognition of high-risk patient factors. These include significant patient comorbidities, especially obesity and liver cirrhosis. Other disease-specific factors are related to the duration and severity of cholecystitis which may cause anatomic distortion in the field of dissection. The surgeon's ability to adequately identify normal hepatocystic (HC) triangle anatomy and recognition of anomalous anatomy are other important surgeon factors involved in preventing BDI. The critical view of safety (CVS) is the best anatomic identification method, with other methods leading to error traps, but it does have some limitations, particularly in the setting of severe inflammation prohibiting safe dissection from obtaining a CVS. Visual heuristics resulting in the anatomic misperception of bile duct location and anatomy and, to a lesser degree, surgeon inexperiences are the most frequent causes of BDI. One important surgical technique includes the consistent use of anatomic landmarks. An example is the Rouviere's sulcus (RS)→segment 4→umbilical fissure (R4U) line which establishes a safe zone of dissection and three-dimensional planar considerations to avoid BDI. Another surgical technique involves the liberal use of intraoperative biliary imaging in cases of uncertain anatomy. In cases in which dissection of the HC triangle is extremely difficult or prohibitive, the surgeon should resort to a bailout procedure such as subtotal cholecystectomy (STC) or conversion to open cholecystectomy (OC). Conclusion: Surgeons should understand and adhere to these tenets of safe LC to decrease the incidence of BDI. Clinical significance: The strategies discussed in this review will allow for a more standardized approach to LC and mitigate the risk of BDI.


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