Research Article: A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases1

Date Published: July 08, 2020

Publisher: Sociedade Brasileira para o Desenvolvimento da Pesquisa em Cirurgia

Author(s): Peizhong Shang, Bing Liu, Xiaowu Li, Jianjun Miao, Ruichang Lv, Weilin Guo.


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.

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.

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.

The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Partial Text

Laparoscopic cholecystectomy (LC) has been regarded as the gold standard for patients with benign gallbladder diseases since its introduction in the late 1980’s and is one of the most widely performed abdominal surgical operations. Laparoscopic procedures have multiple advantages including less postoperative pain, smaller scars, shorter hospitalization, and an earlier return to full activity over open cholecystectomy1. However, the incidence for bile duct injury (BDI) remains more frequent than that seen in the era of open surgery2, where the BDI rates were only 0.1%-0.2%3.

A series of patients with benign gallbladder diseases who underwent LC at our center from March 2007 to February 2019 were retrospectively reviewed. Patients with the following conditions were excluded: acute or atrophic cholecystitis with severe inflammation and fibrosis of the hapatocystic triangle, Mirizzi syndrome, and malignancies. This study was approved by the Research Ethics Committee of the Hospital of PLA 81st Group Army, Hebei and written informed consents were obtained from all the participants. All preoperative diagnoses were made by ultrasonography and magnetic resonance cholangiopancreatography (MRCP). Demographic and pathologic information of included patients was recorded (Table 1).

During the study period, 5539 patients underwent a successful laparoscopic operation, consisting of 4193 females and 1346 males (mean age 56.2 years, range 22–84 years). Most (68.8%) of the patients underwent surgery for chronic cholecystitis, followed by 11.1% for acute cholecystitis, 10.8% for subacute cholecystitis, and 3.0% for atrophic cholecystitis, while the remaining 7.5 % for gallbladder polyps.

There has been a sharp rise in the incidence of BDI since the introduction of LC. Although the surgical technique and laparoscopic equipment, as well as the surgeon’s learning curve have improved, the incidence of BDI is still higher in comparison to the era of open surgery, with a rate noted from approximately 0.2% to about 1.1%, and remains one of the most serious iatrogenic surgical complications2,6,8,12,15. Despite the scarcity of clinical evidence on its precise mechanism, clinical experience shows that most BDI occurs as a result of misidentification of the cystic structures, such as misidentification of the common bile duct, an aberrant bile duct or the common hepatic duct as the cystic duct7-9. Therefore, a reliable method of ductal identification is crucial to prevent BDI.

The gallbladder infundibulum is variable in shape but has a certain regularity, which is useful as a navigator for ductal identification. This, therefore, can help to reduce BDI and improve the safety of LC.




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