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Adopting Culture of Safety for LC
• Availability of a detached observer in all cases. The bystander Table 3: Bailout options adopted
surgeon would stand by monitor to watch and observe the Options Numbers Percentage
procedure with a keen intent and would alert the operating (i) Open cholecystectomy 11 2.87%
surgeon if any wrong space of dissection was entered or
incorrect duct was being dissected. To ascertain this, the (ii) Subtotal cholecystectomy 7 1.83%
bystander surgeon would always ensure that the operating (a) Open 5 1.30%
surgeon is ventral to Rouviere’s sulcus when present and has (b) Lap 2 0.52%
achieved CVS before clipping and dividing any structure. (iii) Tube cholecystectomy 1 0.26%
Minute-to-minute feedback was provided by the detached
observer in difficult situations, so that the surgeon can accept
the need for plan modification if by a given hypothesis Table 4: Indications for bailout
placement of cognitive map is a misfit. 1. Inability to achieve CVS 7/19 36.84%
• Adopting bailout options as merited by the situation early in (a) Tissue inflammation 6/19 31.57%
course of procedure. (b) Fibrosis of Calot triangle 5/19 26.3%
For logistic reasons, intraoperative cholangiography (IOC) (c) Severe adhesion 4/19 21.05%
was not done in our hospital. All patients were advised to attend (d) Unclear anatomy 3/19 15.79%
outpatient clinics at regular intervals of 1 week, 1 month, and 2. Inability to procced at expected pace 2/19 10.52%
6 months. Telephonic communication was kept for any patient who 3. Technical difficulties in handling GB 2/19 10.52%
defaulted to visit outpatient clinics. 4. Contracted/shrilled GB 2/19 10.52%
5. Bleed in surgical field (from GB bed) 1/19 10.52%
results 6. Cirrhotic liver with varices in hepatocystic 1/19 5.26%
Mean age of patients was 43 years (range 16–82 years). Two- triangle
hundred and ninety-eight (78%) patients were females, and 84 7. Hidden GB 1/19 5.26%
(22%) were male, with a male female ratio of 1:3.54. Indication of 8. Mirzzi syndrome 1/19 5.26%
surgery is detailed in Table 1. Most common indication was chronic 9. Hemodynamic instability secondary to 1/19 5.26%
cholecystitis in 213 patients (55.7%). Adaptation of components of pneumoperitoneum
safe cholecystectomy is detailed in Table 2. CVS was achieved in 10. Suspected GB malignancy 1/19 5.26%
256 patients (67%). Rouviere’s sulcus was present in 242 patients
(63.3%). Intraoperative time-out was done in all patients. Bystander
surgeon (independent second observer) was present in all cases. hospital stay was 24 hours in laparoscopic group and 72 hours in
Bailout option as shown in Table 3 was adopted in 19 patients open cholecystectomy subset of patients. No patient was lost to
(4.97%). Conversation to open cholecystectomy was done in 11 of follow up. In our study, there was no instance of BDI. We report a low
the 382 patients (2.87%). Subtotal cholecystectomy was done in 7 conversion rate of 2.5% and is probably because of exclusion criteria
of the 382 (1.83%) patients. In two patients, it was possible to do a adopted by us (Table 4).
laparoscopic subtotal cholecystectomy. Tube cholecystostomy was
done in one patient (1.3%). Reason for adopting bailout options are dIscussIon
discussed in Table 4. Most common indication was inability to achieve
CVS. Mean duration of surgery was 48 minutes. Mean duration of Gallstone disease is a common disease affecting general adult
8,9
population. LC has evolved as the standard of care treatment
for management of this disease due to its various advantages. 10–12
Table 1: Indications of cholecystectomy
Although it is invariably accepted as a safe procedure, complications
Indications No. Percentage still happen in approximately 5% of patient. Of these, BDI remains
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Chronic cholecystitis 213 55.7% the most feared and dreadful complication of LC that at times can be
Acute cholecystitis 81 18.84% life-threatening. The etiology is multifactorial, but misidentification
Biliary colic 72 21.20% of anatomy is perhaps the most important factor responsible for
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Asymptomatic gallstone 13 3.4% BDI mishap. Way et al. concluded that primary cause of BDI was
disease a visual perceptual illusion in which the surgeon misidentifies
Biliary pancreatitis 7 1.83% common bile duct (CBD) as cystic duct. Erroneous technical skills
Gb polyp 4 1.047% were identified as the primary mechanism of injury in only 3% of
6
cases. To minimize the risk of BDI, SAGES, in 2014, formed the
Empyema 3 0.78%
Safe Cholecystectomy Task Force, with the aim of propagating a
7
culture of safety around LC. Following six steps were described to
Table 2: SAGES safe cholecystectomy components (tailored to rural create a culture of safe cholecystectomy and minimize the risk of
setting) BDI: (a) identification of the cystic duct and artery by using CVS, (b)
Components Numbers Percentage awareness of the potential for aberrant anatomy, (c) identification of
(a) Use of CVS 256 67.01% anatomy using IOC or any other relevant method, (d) intraoperative
time-out or pause during surgery before clipping and dividing the
(b) Starting dissection from fixed point 242 63.35% structures in Calot’s triangle for verification of anatomy, (e) early
(c) Use of intraoperative timeout 382 100% adaptation of the bailout options, (f) call for help from another
(d) Availability of a bystander surgeon 382 100% surgeon whenever required.

192 World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021)