A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Abstract

Purpose Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury. Methods A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images. Results All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury. Conclusion The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Analysis of risk factors for bile duct injury in laparoscopic cholecystectomy in China: A systematic review and meta-analysis

“…In addition, the anatomic variations of the gallbladder triangle were recognized as a risk factor for LC-related bile duct injury. [ 19 , 20 ] Approximately 70% to 80% of iatrogenic bile duct injuries occur because of the incorrect identification of biliary tract anatomical structure, [ 21 ] and anatomic variations render it difficult to distinguish between the cystic duct, the common hepatic duct, and the common bile duct. Bile duct variations are diverse, with the parallel or spiral confluence of the cystic duct and the common hepatic duct being the most common cause of bile duct injury.…”

The Laparoscopic Anatomy of Rouviere’s Sulcus

“…4 Therefore, precise identification of frequently variable biliary anatomy is a key factor in prevention of BDI during LC. 5 Critical view of safety (CVS) is an operative strategy to prevent BDI by using various anatomical landmarks during LC. 6 Rouviere's sulcus is a naturally occurring fissure on the visceral surface of the junction between right and caudate lobe.…”

Indocyanine Green Imaging in Laparoscopic Cholecystectomy Plus Laparoscopic Common Bile Duct Exploration: A Suitable Option for Patients With Difficult Exploration (With Videos)

“…Approximately 70% to 80% of BDI cases are due to unclear biliary anatomy. 8,9 Various intraoperative visualization techniques and equipment have been developed to improve the safety of LC, which involves 2 intraoperative imaging techniques: x-ray-based intraoperative cholangiography (IOC) and fluorescence-based intraoperative near-infrared cholangiography. Currently, IOC is the gold standard for intraoperative assessment of biliary anatomy; however, this technique is associated with prolonged operation time, increased surgical costs, and increased risk of radiation exposure among medical staff.…”

“…Bile duct injury (BDI) is a serious complication of biliary tract surgeries. Approximately 70% to 80% of BDI cases are due to unclear biliary anatomy 8,9. Various intraoperative visualization techniques and equipment have been developed to improve the safety of LC, which involves 2 intraoperative imaging techniques: x-ray-based intraoperative cholangiography (IOC) and fluorescence-based intraoperative near-infrared cholangiography.…”