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Adopting Culture of Safety for LC
The CVS has been adapted for clear identification of structures the CVS is achieved or not, whether it is safe to continue dissection
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in Calot’s triangle to reduce the risk of BDI. The requirements are in the assumed plane, and when to apply stopping rules. Kapoor
as follows: The hepatocystic triangle must be cleared of all the fatty also suggests that the primary surgeon should always call another
and fibrous tissue. Second, the lowest one-third of the gallbladder surgical colleague for opinion and assessment of the biliary ductal
must be separated from the liver bed. The third requirement is anatomy, if in doubt, before the structures of Calot’s triangle are
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to ensure that only two structures are seen to be entering the divided. The new and unbiased input of the detached observer
gallbladder. Once these three criteria have been fulfilled, CVS is can avoid the visual perception error of the primary surgeon. He
said to be attained. Most surgeons around the world acknowledge calls this “in vicinity colleaguography.”
the importance of CVS during LC for prevention of biliary injury. 16,17 Bystander surgeon for the reason that he is detached is more
There has been indirect evidence from literature to suggest that the likely to seek information from surgical field and more likely
use of the CVS is helpful in preventing BDI. None of the patients in to recognize misplacement of cognitive map by the operating
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the study conducted by Yegiyants and Collins had an injury to biliary surgeon that can result in spatial disorientation. He is more alert
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ducts because of visual misidentification when CVS was achieved. for cues from surgical environment if demanded by the situation.
CVS was achieved in 998 of the 1,046 patients in the study He can refute the working hypothesis which the operator has
conducted by Avgerinas et al. who reported a conversion rate of entertained. Significance of unexpected observation may go
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2.7%. Five patients had minor bile leak that resolved spontaneously. unrecognized by the operating surgeon due to conformation bias.
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They didn’t report any major BDI. Heistermann et al. evaluated 100 Since detached observer is not committed to a judgment and is
patients who had LC in whom CVS was achieved. Only one patient free from confirmation bias, he may be able to attach significance
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in their study had postoperative cystic duct stump leak. 19 to some unexpected observation. As mentioned by Way et al.
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Variations in biliary anatomy are common. Variable biliary in their seminal paper, “human performance cannot be pushed
anatomy can predispose to BDI. Awareness to variation in biliary to perfection and that most fruitful correction strategy often lies
6
anatomy can be enhanced by starting from a fixed point a concept outside the individual.” Bystander surgeon can be considered as
20
borrowed by Huge from maritime and aviation industries. one such outside correction strategy. 31
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Rouviere’s sulcus is one such extra biliary fixed point. The right Alternative or bailout options should be considered in
portal pedicle runs in this fissure and thus demarcates the plane those cases where achievement of CVS remains elusive due to
14
of the porta hepatis. The dissection during the procedure should dense adhesions, uncertain anatomy, or severe inflammation.
always stay anterior to this sulcus. Minimal incidence of BDI has Conversion to open cholecystectomy is the most practical option
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been reported in a large series of LC by Huge et al. and Singh and in this situation. The decision to convert to open should take into
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Ohri when dissection is done ventral to this sulcus. consideration the experience of surgeon since difficult LC usually
As per SAGES recommendations, it is advised to keep IOC suggests a difficult open cholecystectomy with chances of biliary
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available as an integral tool while performing LC. Selective use, injuries remaining higher. Subtotal cholecystectomy may also
23
however, has been practiced more commonly. Utility of IOC be considered in select situations. It can be done by laparoscopic
is, however, controversial as many authors report it to be time- or open method. Surgical cholecystostomy tube drainage is a safe
consuming and complex procedure. It is also considered to be alternative in difficult situations. In case of inexperience, the best
inefficient with few authors suggest that many surgeons may not possible method to prevent BDI may be to abort the procedure and
be able to read it correctly. 24,25 As per the current literature, there referral to the higher center.
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is no level evidence to suggest the use of IOC. An alternative
is laparoscopic ultrasonography, but it is subject to significant conclusIon
interoperator variability. 27,28 Another method to identify and SAGES culture of safe cholecystectomy can be modified to make it
continuously map the biliary anatomy is near-infrared fluorescent applicable to rural hospitals in developing countries, where due to
cholangiography, which is technically easy but the data as of now are logistic and other reasons, IOC is not available. More reliance can
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insufficient to suggest its role in minimizing biliary injury. Due to the be put on a detached bystander surgeon who is likely available in
lack of expertise or for logistic reasons, these methods of mapping the vicinity.
biliary anatomy are not available in most rural hospitals in India.
Intraoperative time-out should be considered by operating orcId
surgeon always in the process of dissection of Calot’s triangle.
This step helps to confirm that the CVS has been achieved. The Mohd Riyaz Lattoo https://orcid.org/0000-0001-7866-9511
proposed disadvantage of this step is that this step is adopted Prince Ajaz Ahmad https://orcid.org/0000-0003-3281-1046
by the operating surgeon who may still suffer from the heuristic Sadaf Ali Bangri https://orcid.org/0000-0002-2496-8935
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error. As already discussed, injuries stem principally from
misidentification secondary to visual misperception rather than references
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error of skill, knowledge, or judgement. This visual misperception 1. Truven health analytics (Thomson/Solucient). USA Procedure
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is a result of misplaced cognitive map, and sometimes this illusion Volumes; 2014.
is so compelling as to end into an error. A detached observer can be 2. National Institutes of Health. National Institute of Health consensus
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helpful in this situation. The detached observer present should development conference statement on gallstones and laparoscopic
agree with the surgeon that CVS has been achieved. Hori et al. cholecystectomy. Am J Surg 1993;165(4):390–398. DOI: 10.1016/s0002-
have also advised to take the opinion of an independent detached 9610(05)80929-8.
surgeon while demonstrating CVS as he is unbiased and free from 3. Connar S and Garden OJ. Bile duct injury in the era of laparoscopic
cholecystectomy. Br J Surg 2006;93(2):158–168. DOI: 10.1002/bjs.5266.
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the any heuristic impression of the primary surgeon. Surgical 4. MacFadyen BV Jr, Vecchio R, Ricardo AE, et al. Bile duct injury after
colleague can act as an unbiased observer free from heuristic laparoscopic cholecystectomy. The United States experience. Surg
impression of operating surgeon. He or she can ascertain whether Endosc 1988;12(4):315–321. DOI: 10.1007/s004649900661.
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