Can bile duct injuries be prevented? "A new technique in laparoscopic cholecystectomy"

Abstract

BackgroundOver the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates. The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct, ductus choledochus and even the gall bladder.Methodsgall bladder fundus was punctured by Veress needle and all the bile was aspirated. The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus.ResultsBetween October 2003 and December 2004, overall 46 patients (of which 9 males) with a mean age of 47 (between 24 and 74) underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis (the thickness of the gall bladder wall was normal) confirmed by pre-operative abdominal ultrasonography in all patients. The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. were documented in 13 cases. One patient was operated for gall bladder polyp (our first case). Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible. None of the patients developed bile duct injury.ConclusionThe number of bile duct injuries related to anatomic misidentification can be decreased and even vanished by using intraoperative methylene blue injection technique into the gall bladder fundus intraoperatively.

Visualizing biliary tracts with isosulphan blue to prevent injury during laparoscopic cholecystectomy: a preliminary cadaveric study

“…Administered isosulphan blue is excreted by a nasogastric catheter, or by being passed into the duodenum. Dye leakage from the injury site allows for repair during the same surgical session using open surgery [10]. This technique is not yet supported by clinical trials; a further limitation pertains to the possibility of failure to stain the cystic and bile ducts if they are obstructed by a stone or inflammation.…”

“…BDI may result in prolonged hospitalization, increased morbidity and mortality, and legal liability. If BDI does occur, peroperative identification and repair represents the optimal method of reducing morbidity and mortality [10].…”

“…1a, b). In a previous clinical study in which they stained the biliary tract with a different dye, the leakage of the residue of the gall bladder was prevented by the same technique [10]. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract.…”

The influence of anatomical variations of the cystic artery inside Calot’s triangle on the surgical procedure in patients with carbon dioxide pneumoperitoneum

“…The technique presented by Sari et al utilized an intraoperative injection of the fundus of the gall bladder with methylene blue. According to the authors such a procedure was very helpful in avoiding anatomical misidentification [33]. The technique presented by Kunsani et al was based on identification of the Calot's triangle lymph node, which was used subsequently as a reference point (end point) in the dissection.…”

Prevention of Common Bile Duct Injuries in Laparoscopic Cholecystectomy

“…Similarly, Sari et al proposed injecting methylene blue in the gallbladder after aspirating the bile with a Varess needle before starting dissection. 27 To overcome the problem of anatomical orientation, before starting dissection, identification of fixed anatomical landmarks is helpful. Hugh recommends identifying Rouviere's sulcus as a fixed extrabiliary point ventral to the right portal pedicle.…”