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                                                   Prevention of Common Bile Duct Injuries in Laparoscopic Cholecystectomy

          removing the gallbladder. It often occurs when the dissection  inflammatory mass within which the cystic duct is hidden
          is difficult especially or when the gallbladder is intrahepatic.  (Figs 2A and B). This visual deception occurs especially in
                                                              presence of severe acute or chronic inflammation, a large
          Thermal injuries:  Cautery induced injuries are also more
                                                              stone in the pouch of Hartmann, adhesive bands between
          common in the presence of severe inflammation. This is
                                                              the gallbladder and the common hepatic duct and
          due to the use of excessively high cautery settings to control
                                                              intrahepatic gallbladder. Chronic inflammation tends to
          hemorrhage.
                                                              cause retraction of structures in the porta hepatis, bringing
          Tenting injuries:  In a tenting injury, the junction of the  the gallbladder against the CHD so that it appears as a part
          common bile duct and hepatic bile ducts is occluded when  of the gallbladder wall. If this view is relied upon for ductal
          a clip is placed at the bottom end of the cystic duct while  identification it will, in these cases, result in division of the
          forcefully pulling up on the gallbladder.           CBD. 18
                                                                 The critical view of safety technique, advocated by
          Prevention of Bile Duct Injuries                    Strasberg involves tentative identification of these cystic
                                                              structures by dissection in the triangle of Calot (Figs 3A
          Bile duct injury should be regarded as preventable, but in a
                                                              and B), followed by dissection of the gallbladder off the
          study of surgeons’ anonymous response after bile duct injury
                                                              liver bed. In this technique, the triangle of Calot is cleared
          during cholecystectomy published in the American Journal
                                                              of fat and fibrous tissue and after detachment of the
          of Surgery in 2003, over 70% of surgeons regarded it as
          unavoidable. 15  Following early experiences with such  gallbladder; only two structures are connected to the lower
                                                              end of the gallbladder—the cystic duct and artery. It is not
          injuries in early 90’s, Hunter and Troidl proposed several
                                                              necessary or recommended that the CBD be visualized. 2
          techniques to prevent injury: A 30º telescope, avoidance of
                                                              Failure to achieve this critical view is an absolute indication
          diathermy close to the common hepatic duct, dissection close
                                                              for conversion or possibly cholangiography to define ductal
          to the gallbladder—cystic duct junction, avoidance of
                                                              anatomy.
          unnecessary dissection close to the cystic duct—common
                                                                 Following its introduction, this critical view method has
          hepatic duct junction, and conversion to an open approach
                                                              been accepted by many surgeons for its superior results with
                        16,17
          when uncertain.   However, to apply these techniques,
                                                              regards to minimizing BDIs. Averginos et al in 2009
          correct interpretation of the anatomy is required.
                                                              published the result of 1046 cholecystectomies without BDI
                                                              using the critical view method. 20  Only five patients had
          Preventing Misidentification Errors
                                                              transient biliary leaks in the postoperative period which
          Misidentification is due to failure to achieve conclusive
                                                              subsided within 2 to 14 days. Similarly, Yegiyants and
          identification of the cystic structures. The cystic duct and  Collins analyzed the role of critical view of safety in 3,000
          artery are the only structures that require division during  patients undergoing elective cholecystectomy and reported
          cholecystectomy, hence the objective of dissection primarily  one bile duct injury, which occurred during dissection of
          is to identify these structures conclusively. There are several  Calot’s triangle, prior to achieving the critical view. 19,21
          methods of identification of the cystic duct. In the open  Sanjay et al in 2010 studied its safety in 447 cholecystec-
          method, display of the confluence of the cystic duct with  tomies done for acute biliary pathologies and reported no
          the common hepatic duct to form the common bile duct  BDIs. Critical view was obtained in 388 (87%) patients and
          was used which is considered not safe in the laparoscopic
          method. In the laparoscopic form of surgery, techniques
          used are intraoperative cholangiography, the infundibular
          technique and the critical view technique.
             The infundibular technique is a method initially used
          for ductal identification based on three-dimensional
          demonstration of the funnel-like shape of the lower end of
          the gallbladder and adjacent cystic duct. To obtain this view,
          cystic duct is followed onto the gallbladder or the lower
          end of the gallbladder is traced down to the cystic duct.
          When dissection is completed, the funnel-shaped union of
                                                               A                      B
          cystic duct with gallbladder can be seen in three dimensions.
                                                              Figs 2A and B:  (A) The usual anatomy when the infundibular
          The fallacy of this technique is obtaining a false  technique is used, (B) anatomical situation in some cases of
          ‘infundibular views’ when the CBD is followed up to an  classical injuries 21

          World Journal of Laparoscopic Surgery, January-April 2012;5(1):27-32                              29
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