Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Register      Login

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


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).


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.

  1. Shaffer EA. Gallstone disease: epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol 2006;20(6):981–996. DOI: 10.1016/j.bpg.2006.05.004
  2. Soper NJ, Brunt LM, Kerbl K. Laparoscopic general surgery. N Engl J Med 1994;330(6):409–419. DOI: 10.1056/NEJM199402103300608
  3. Barrett M, Asbun HJ, Chien HL, et al. Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surg Endosc 2018;32(4):1683–1688. DOI: 10.1007/s00464-017-5847-8
  4. Booij KAC, de Reuver PR, van Dieren S, et al. Long-term impact of bile duct injury on morbidity, mortality, quality of life, and work related limitations. Ann Surg 2018;268(1):143–115. DOI: 10.1097/SLA.0000000000002258
  5. Tornqvist B, Zheng Z, Ye W, et al. Long-term effects of iatrogenic bile duct injury during cholecystectomy. Clin Gastroenterol Hepatol 2009;7(9):1013–1018. DOI: 10.1016/j.cgh.2009.05.014
  6. Flum DR, Cheadle A, Prela C, et al. Bile duct injury during cholecystectomy and survival in Medicare beneficiaries. JAMA 2003;290:2168–2173. DOI: 10.1001/jama.290.16.2168
  7. Halbert C, Pagkratis S, Yang J, et al. Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era. Surg Endosc 2016;30(6):2239–2243. DOI: 10.1007/s00464-015-4485-2
  8. Gartland RM, Bloom JP, Fong ZV, et al. What have we learned from malpractice claims involving the surgical management of benign biliary disease?: A 128 million dollar question. Ann Surg 2019;269(5):785–791. DOI: 10.1097/SLA.0000000000003155
  9. Carroll BJ, Birth M, Phillips EH. Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 1998;12(4):310–313. DOI: 10.1007/s004649900660
  10. Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2018;25(1):73–86. DOI: 10.1002/jhbp.517
  11. Brunt LM, Deziel DJ, Telem DA, et al. Multi-society practice guideline and state of the art consensus conference on prevention of bile duct injury during cholecystectomy. Ann Surg 2020;272(1):3–23. DOI: 10.1097/SLA.0000000000003791
  12. Iwashita Y, Hibi T, Ohyama T, et al. Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework? J Hepatobiliary Pancreat Sci 2017;24(11):591–602. DOI: 10.1002/jhbp.503
  13. Conrad C, Wakabayashi G, Asbun HJ, et al. IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci 2017;24(11):603–615. DOI: 10.1002/jhbp.491
  14. Club SS. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991;324(16):1073–1078. DOI: 10.1056/NEJM199104183241601
  15. Roslyn JJ, Binns GS, Hughes EF, et al. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993;218(2):129–137. DOI: 10.1097/00000658-199308000-00003
  16. Pucher PH, Brunt LM, Davies N, et al. SAGES Safe Cholecystectomy Task Force. Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis. Surg Endosc 2018;32(5):2175–2183. DOI: 10.1007/s00464-017-5974-2
  17. Ayloo S, Roh Y, Choudhury N. Laparoscopic versus robot-assisted cholecystectomy: a retrospective cohort study. Int J Surg 2014;12(10):1077–1081. DOI: 10.1016/j.ijsu.2014.08.405
  18. Khan MN, Azim A, Nishida S, et al. Does Robotic approach in cholecystectomy increase the chance of bile duct injury? An in-depth analysis of national database. J Am Coll Surg 2021;233(5):e109. DOI: 10.1016/j.jamcollsurg.2021.08.292
  19. Angelou A, Damaskos C, Garmpis N, et al. An analysis of the iatrogenic biliary injury after robotic cholecystectomy. Current data and future considerations. Eur Rev Med Pharmacol Sci 2018;22(18):6072–6076. DOI: 10.26355/eurrev_201809_15945
  20. Blumgart LH, Schwartz LH, DeMatteo RP, et al. Surgical and radiological anatomy of the liver, biliary tract, and pancreas. Jarnagin WR, Allen PJ, Chapman WC, D’Angelica MI, DeMatteo RP (Eds). Blumgart's Surgery of the liver, biliary tract, and pancreas. Philadelphia: Elsevier 2017;32–59.
  21. Gupta V, Jain G. The R4U planes for the zonal demarcation for safe laparoscopic cholecystectomy. World J Surg 2021;45(4):1096–1101. DOI: 10.1007/s00268-020-05908-1
  22. Rothman J, Burcharth J, Pommergaard HC, et al. Preoperative risk factors for conversion of laparoscopic cholecystectomy to open surgery – a systematic review and meta-analysis of observational studies. Dig Surg 2016;33(5):414–423. DOI: 10.1159/000445505
  23. Archer S, Brown D, Smith C, et al. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234(4):549–559. DOI: 10.1097/00000658-200110000-00014
  24. Schwaitzberg S, Scott D, Jones D, et al. Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed. Surg Endosc 2014;28(11):3068–3073. DOI: 10.1007/s00464-014-3580-0
  25. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237(4):460–469. DOI: 10.1097/01.SLA.0000060680.92690.E9
  26. Daly SC, Deziel DJ, Li X, et al. Current practices in biliary surgery: Do we practice what we teach? Surg Endosc 2016;30(8):3345–3350. DOI: 10.1007/s00464-015-4609-8
  27. Stefanidis D, Chintalapudi N, Anderson-Montoya B, et al. How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy? Surg Endosc 2017;31(1):142–146. DOI: 10.1007/s00464-016-4943-5
  28. de Mestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis. Ann Surg 2014;259(1):10–15. DOI: 10.1097/SLA.0b013e3182a5cf36
  29. Tornqvist B, Waage A, Zheng Z, et al. Severity of acute cholecystitis and risk of iatrogenic bile duct injury during cholecystectomy, a population-based case-control study. World J Surg 2016;40:1060–1067. DOI: 10.1007/s00268-015-3365-1
  30. Hirota M, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14(1):78–82. DOI: 10.1007/s00534-006-1159-4
  31. Hernandez M, Murphy B, Aho JM, et al. Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines. Surgery 2018;163(4):739–746. DOI: 10.13039/100016220
  32. Madni T, Nakonezny P, Barrios E, et al. Prospective validation of the Parkland Grading Scale for cholecystitis. Am J Surg 2019;217(1):90–97. DOI: 10.1016/j.amjsurg.2018.08.005
  33. Madni T, Nakonezny P, Imran J, et al. A comparison of cholecystitis grading scales. J Trauma Acute Care Surg 2019;86(3):471–478. DOI: 10.1097/TA.0000000000002125
  34. Adkins RB, Chapman WC, Reddy VS. Embryology, anatomy, and surgical applications of the extrahepatic biliary system. Surg Clin North Am 2000;80(1):363–379. DOI: 10.1016/s0039-6109(05)70410-2
  35. Dekker SW, Hugh TB. Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. ANZ J Surg 2008;78(12):1109–1114. DOI: 10.1111/j.1445-2197.2008.04761.x
  36. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180(1):101–125. PMID: 8000648
  37. Strasberg SM, Brunt LM. The critical view of safety: why it is not the only method of ductal identification within the standard of care in laparoscopic cholecystectomy. Ann Surg 2017;265(3):464–465. DOI: 10.1097/SLA.0000000000002054
  38. Tsalis K, Antoniou N, Koukouritaki Z, et al. Open-access technique and ”critical view of safety” as the safest way to perform laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2015;25(2):119–124. DOI: 10.1097/SLE.0000000000000055
  39. Avgerinos C, Kelgiorgi D, Touloumis Z, et al. One thousand laparoscopic cholecystectomies in a single surgical unit using the ”critical view of safety” technique. J Gastrointest Surg 2009;13(3):498–503. DOI: 10.1007/s11605-008-0748-8
  40. Nijssen MA, Schreinemakers JM, Meyer Z, et al. Complications after laparoscopic cholecystectomy: a video evaluation study of whether the critical view of safety was reached. World J Surg 2015;39(7):1798–1803. DOI: 10.1007/s00268-015-2993-9
  41. Strasberg SM. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg 2008;15(3):284–292. DOI: 10.1007/s00534-007-1267-9
  42. Dahmane R, Morjane A, Starc A. Anatomy and surgical relevance of Rouviere's sulcus. Sci World J 2013;2013(4):254287. DOI: 10.1155/2013/254287
  43. Strasberg SM, Belghiti J, Clavien PA, et al. The Brisbane 2000 terminology of liver anatomy and resections. HPB 2000;2(3):333–339. DOI: 10.1016/S1365-182X(17)30755-4
  44. Alvarez FA, de Santibañes M, Palavecino M, et al. Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Br J Surg 2014;101(6):677–684. DOI: 10.1002/bjs.9486
  45. Machi J, Johnson JO, Deziel DJ, et al. The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc 2009;23(2):384–388. DOI: 10.1007/s00464-008-9985-x
  46. Dip F, LoMenzo E, Sarotto L, et al. Randomized trial of near-infrared incisionless fluorescent cholangiography. Ann Surg 2019;270(6):990–999. DOI: 10.1097/SLA.0000000000003178
  47. Strasberg SM, Pucci MJ, Brunt LM, et al. Subtotal cholecystectomy-” fenestrating” vs ”reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016;222(1):89–96. DOI: 10.1016/j.jamcollsurg.2015.09.019
  48. Mangieri CW, Hendren BP, Strode MA, et al. Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc 2019;33(3):724–730. DOI: 10.1007/s00464-018-6333-7
  49. Elshaer M, Gravante G, Thomas K, et al. Subtotal cholecystectomy for ”difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 2015;150(2):159–168. DOI: 10.1001/jamasurg.2014.1219
  50. Suzuki K, Bower M, Cassaro S, et al. Tube cholecystostomy before cholecystectomy for the treatment of acute cholecystitis. JSLS 2015;19(1):e2014.00200. DOI: 10.4293/jsls.2014.00200
  51. de’Angelis N, Catena F, Memeo R, et al. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021;16(1):30–57. DOI: 10.1186/s13017-021-00369-w
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.