This document discusses techniques for performing safe laparoscopic cholecystectomy to avoid bile duct injury. It emphasizes obtaining the "critical view of safety" during surgery, which involves clearly exposing the two structures entering the gallbladder without exposing the common bile duct. Failure to obtain this view and excessive traction on structures are common causes of bile duct injury. If injury occurs, prompt recognition and repair by an expert is important to avoid complications. New minimally invasive approaches for hepatopancreaticobiliary surgery are also discussed.

1. Safe Laparoscopic Cholecystectomy
Modern Advancements in HepatoPancreatoBiliary Surgery
Iswanto Sucandy, M.D
Florida Hospital, Tampa, FL
Minimally Invasive and Robotic Surgery
HepatoPancreatoBiliary and Advanced Gastrointestinal Surgery

2. Disclosures
 No disclosures
 I fix bile duct injuries (many are very painful
operations)

3. Introduction
 Introduced in late 1980’s
 Most commonly performed operation
 Over 700,000 cases annually in USA
 Bile duct injury after Lap Cholecystectomy : 0.5-0.8%
 Bile duct injury after Open Cholecystectomy : 0.1-
0.2%
 Litigation claims - average settlements of up to
$500,000 USD
 Morbidity and Mortality
 SAGES Safe Cholecystectomy Task Force

4. Causes of Lap chole bile duct injury/leak
- Misidentification of anatomical structures
- Failure to occlude cystic duct stump securely
- Plane of GB dissection into the liver bed
- Excessive traction on cystic duct off the common
hepatic duct - “tenting injury”
- Improper technique of ductal exploration
- Injudicious use of electrocautery for
dissection/hemostasis
- Injudicious use of clips for hemostasis

5. Biliary Anatomy – Type of Union Cystic duct - CHD
a. Angular Union
b. Paralell Union
c. Spiral Union

6. Biliary Anatomy – Hepatic duct confluence

7. Biliary Anatomy – Low insertion Right Posterior
Hepatic Duct
Cystic duct
stump
Right
posterior
hepatic duct

8. Laparoscopic cholecystectomy
Excessive traction
on cystic duct
“tenting injury”

9. Bile Duct Injury – Laparoscopic
Cholecystectomy
 1st most common cause : misidentification of CBD to
be cystic duct
 2nd most common cause : injury to the aberrant right
posterior hepatic duct
 Identification techniques :
 Infundibular Technique
 Critical View of Safety

10. Bile Duct Injury – Laparoscopic
Cholecystectomy
 1st most common cause : misidentification of CBD to
be cystic duct
 2nd most common cause : injury to the aberrant right
posterior hepatic duct
 Identification techniques :
 Infundibular Technique NO !!
 Critical View of Safety YES
** Bile duct injury usually associated with Right Hepatic
Artery injury – 20% **

11. Critical View of Safety
1. Triangle of Calot must be cleared of fat & fibrous
tissues
2. Lowest part of GB must be separated from cystic
plate
3. Two structures & only two are seen entering the
GB

12. Laparoscopic cholecystectomy

13. Laparoscopic cholecystectomy

14. Gallbladder
Common Bile Duct (do not
dissect/expose)
Cystic
duct
Cystic
artery
Critical View of Safety

15. Critical View of Safety – front view Critical View of Safety – posterior
view

17. “ 2 windows “
dissection
Critical View of Safety

18. CVS is difficult to obtain ?
 Options :
 Intraoperative cholangiography
 Help from a colleague
 Conversion to an open cholecystectomy
 When CVS unobtainable – laparoscopic subtotal
cholecytectomy , fenestrating cholecytectomy

19. Infundibular Technique

20. Infundibular Technique
Easier but why this
technique should not
be used
CHD
Very short
cystic duct

21. What you do not want to see during
laparoscopic cholecystectomy

22. What you do not want to see

23. What you do not want to see postoperatively

24. Type of Bile Duct Injury

25. Summary - how to avoid bile duct injury ?
 Proper identification of anatomy
 Careful dissection to achieve critical view of safety
 Avoid excessive traction during dissection of Calot
triangle
 Plane of dissection should be close to GB wall
 Avoid excessive use of electrocautery
 Avoid blind clipping for hemostasis
 Gentle tissue manipulation during CBDE

26. When bile duct injury occurs, what to do ?..
 Recognized intraoperatively – refer to an HPB expert /center
for immediate repair/reconstruction
 Recognized in immediate postoperative period – delayed
repair in 2-3 weeks. Focus : control of biliary
leakage/infection/sepsis,
 Delayed presentation –biliary tract reconstruction in delayed
fashion.
Presenting signs of biliary injury/leak :
- Abdominal pain (bile peritonitis), distension, and fever
- Jaundice / elevated LFTs
- Bile leakage from incision

27. Minimally Invasive HPB
Minimally Invasive HPB
 Laparoscopic Approach
 Robotic Approach
Minimally Invasive HPB
 MIS Whipple Procedure
 MIS Biliary Tract Surgery
 MIS Liver Resection
Advanced procedures, significant learning curve ++

28. Robotic Whipple Procedure

29. Robotic Whipple Procedure

30. Robotic Whipple Procedure

31. Robotic Biliary Tract Surgery

32. Laparoscopic Liver Resection

33. Laparoscopic Liver Resection

34. Robotic Liver Resection

35. Robotic Liver Resection

36. Robotic Liver Resection

37. Laparoscopic left lateral sectionectomy

38. References
 1. Strasberg SM, Brunt LM. Rationale and use of the critical
view of safety in laparoscopic cholecystectomy. J Am Coll
Surg. 2010 Jul;211(1):132-8.
 2. Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas.
5 th Edition Elsevier 2012.
 3. Bonrath EM, Dedy NJ, Zevin B, Grantcharov TP.
International consensus on safe techniques
and error definitions in laparoscopic surgery. Surg
Endosc. 2014 May;28(5):1535-44.
 4. Callery MP. Avoiding biliary injury during laparoscopic
cholecystectomy: technical considerations. Surg Endosc. 2006
Nov;20(11):1654-8
 Pucher PH, Brunt LM, Fanelli RD, et al.
SAGES expert Delphi consensus: critical factors for safe
surgical practice in laparoscopic cholecystectomy. Surg
Endosc. 2015 Nov;29(11):3074-85.