Your Road to Safer Lap Choles

For all the benefits of laparoscopic cholecystectomy, a persistent problem continues to plague one of the most commonly performed surgical procedures: bile duct injuries (BDIs). This dreaded complication can turn an otherwise routine same-day gallbladder removal into an emergency — and a medical malpractice suit. BDIs are the No. 1 litigated case against surgeons, responsible for 1 in 5 malpractice claims.

What is the frequency of BDIs? It's relatively rare — it's estimated that only 0.4% of lap chole complications results in BDIs — but that translates to about 3,000 nicked, burned or pinched bile ducts per year when you consider that surgeons laparoscopically remove 750,000 to 1 million gallbladders annually. BDIs lead to symptoms that can be painful, even deadly, if not treated. Here are tips to make a safe operation safer.

One approach toward improving safety is standardizing dissection of the gallbladder during surgery by creating a "critical view of safety" — a technique endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). SAGES suggests these 6 strategies that surgeons can employ to adopt a universal culture of safety for cholecystectomies that minimizes the risk of BDIs.

Use the Critical View of Safety (CVS) method to identify the cystic duct and cystic artery during lap choles. The 3 criteria required to achieve the CVS are:

• clear the hepatocystic triangle — the triangle formed by the cystic duct, the common hepatic duct and the inferior edge of the liver — of fat and fibrous tissue;
• separate the lower one-third of the gallbladder from the liver to expose the cystic plate, also known as the liver bed of the gallbladder; and
• see 2 and only 2 structures when entering the gallbladder.

Understand the potential for aberrant anatomy in all cases. Aberrant anatomy may include a short cystic duct, aberrant hepatic ducts or a right hepatic artery that crosses anterior to the bile duct.

Make liberal use of cholangiography or other methods to image the biliary tree intraoperatively. Cholangiography may be especially important in difficult cases or unclear anatomy. Studies have shown that cholangiography reduces the incidence and extent of bile duct injury, but the subject remains controversial.

Take an intraoperative time out during a lap chole before clipping, cutting or transecting any ductal structures. The time out should consist of a stop point in the operation to confirm that you've achieved the CVS.

Recognize when the dissection is approaching a zone of significant risk and halt the dissection before entering the zone. Finish the operation by a safe method other than cholecystectomy if conditions around the gallbladder are too dangerous. In situations where there is severe inflammation in the porta hepatis and neck of the gallbladder, the CVS can be difficult to achieve. The fact that achieving the CVS appears not feasible is a key benefit of the method, as it alerts you to possible danger of injury.

Get help from another surgeon when the dissections or conditions are difficult. When it is practical to obtain, the advice of a second surgeon is helpful under conditions in which the dissection is stalled, the anatomy is unclear or under other conditions deemed difficult by the surgeon.

Though rare, the reality is that BDIs still occur during lap choles. Any technique or technology that can help eliminate the risk of injury to the common bile duct structure is worth considering. OSM