Laparoscopic cholecystectomy (Phẫu thuật nội soi cắt túi mật - Cắt túi mật khó).pptx

On September 12, 1985, Erich Muhe (1938–2005), from
Erlangen, Germany, performed the first planned
cholecystectomy using a local manufacturing
laparoscope

Jarnagin, W. R. (2023). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set, 7th Edition. Elsevier.

The “difficult gallbladder” is a scenario in which a
cholecystectomy turns into an increased surgical risk
compared with standard cholecystectomy

The primary goal of a LC in the treatment of
symptomatic cholelithiasis is the safe remotion of
the GB & the absence of CBDI.

Contents
1. INTRODUCTION
2. PREDICT A DIFFICULT LC
3. SURGICAL ANATOMY
4. CRITICAL VIEW OF SAFETY
5. STEPS OF SAFE LC

Contents
6. SPECIAL SITUATIONS
7. CHOLANGIOGRAPHY
8. TROUBLESHOOTING
9. ERRORS AND “NEAR MISSES”
10. FINAL REMARK

Introduction
Kapoor, V.K. Mohammad Ibrarullah and SS Sikora: The Safe Laparoscopic Cholecystectomy: An Illustrated Atlas. Indian J Surg 84, 1156–1157 (2022). https://doi.org/10.1007/s12262-021-03155-9
• Laparoscopic cholecystectomy (LC) is the commonest
abdominal surgery, over 750,000 cases done in the
United States annually
• The incidence following LC is in the range 0.36–1.5%
• Bile duct injury (BDI) is the most sinister complication
=> Prolonged morbidity, increased hospitalization cost,
possible litigation

Introduction
Kapoor, V.K. Mohammad Ibrarullah and SS Sikora: The Safe Laparoscopic Cholecystectomy: An Illustrated Atlas. Indian J Surg 84, 1156–
1157 (2022). https://doi.org/10.1007/s12262-021-03155-9
• Factors: lack of experience, anatomical variations,
inflammatory
>90% of cases the injury “perception error”
• The most common perception errors
 Mistaking the CBD for a CD
 Misidentifying the (R) hepatic artery as cystic artery

Difficult Cholecystectomy: How to Prevent Biliary Injuries
• 34–49% of surgeons are expected to cause such an
injury during their professional career activity
• The repair is complex; impact of quality of life,
functional status, survival
Introduction

Evaluation of Patients
1157 (2022). https://doi.org/10.1007/s12262-021-03155-9
Recognition of a potentially difficult GB is the first step
toward mitigating the high risks of operating
General evaluation
Pulmonary, cardiac status, control of diabetes, elderly
patients with multiple comorbidities

Evaluation of Patients
Disease evaluation
Complete history, physical examination, blood counts, liver
function & renal function test
 USG: the primary investigation
 CT scan: suspected empyema, perforation, pancreatitis,
focal wall thickening, mass lesion seen on USG
 MRCP & EUS: suspicion of CBD stones

When to Predict a
Difficult Laparoscopic
Cholecystectomy

Factors associated with difficult LC

CONVERSION
• A “bail out” option
• Conversion should NOT be considered a failure of the
procedure, but a MATURE judgment
• Conversion could be an “elective conversion” as in:
 Anatomy not clearly defined
 Obliterated hepatocystic triangle with dense adhesions
 Non-progression of dissection after adequate trial

• Conversion could be a “forced conversion” as in:
 Bleeding–unable to determine site/uncontrolled bleeding
 Bile leak from the hilum, anatomy undefined
 BDI recognized on the operating table
 Injury to an adjacent hollow viscera
 A large cholecysto-enteric fistula
CONVERSION

Conversion from Laparoscopic to Open
Cholecystectomy (CLOC) risk score
Conversion

CBD stone/s
• CBD: 5–20% cholecystectomy
• Asymptomatic CBD stones <5% with normal liver function
test & USG findings
• USG : sensitivity of 71%, specificity of 91%
• MRCP & EUS: sensitivity & specificity of >95% for each
Kapoor, V.K. Mohammad Ibrarullah and SS Sikora: The Safe Laparoscopic Cholecystectomy: An Illustrated Atlas. Indian J Surg 84, 1156–1157 (2022).

Predictors of CBD stone/s

CBDS common bile duct stone; (+) CBD stone present; (−) CBD stone absent
Approach to patients with suspected CBDS according to the risk stratification

R4U LINE
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• R4U line: an imaginary line (yellow
dotted line) passing through RS, base
of segment 4, umbilical fissure
• Safe dissection for
cholecystectomy should remain
above this plane

https://doi.org/10.1007/s12262-021-03155-9
Anatomical landmarks and planes for
safe dissection
Supero-lateral quadrant (shaded area)
is considered the ”safe zone”
“Safe zone”

• A guide to the cystic artery
• Cystic LN line: the line running through the cystic
lymph node and parallel to the hepatoduodenal
ligament
Cystic lymph
node
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Cystic LN line, R4U line and the safe zone of dissection (dotted green circle)

• Angular – parallel – spiral insertion of CD in 75%,
20% and 5% of cases
• Join (R) hepatic duct/(R) sectoral duct: 0.6–2.3%
• Rarely absent, due to inflammatory shortening or
erosion by a stone (Mirizzi syndrome)
Cystic duct
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(a) angular insertion, (b)
high insertion, (c) absent
CD, (d) parallel CD, (e)
parallel CD fused with the
CBD, (f) spiral posterior CD,
(g) spiral anterior CD

• Termed incorrectly “ducts of Luschka”
• Close proximity to the GB bed
• 34.5% of cases (recent review reported incidence
of 3%–10%)
• Mean diameter: ≤2 mm
Subvesicle
duct
https://doi.org/10.1007/s12262-021-03155-9
“Ducts of Luschka”?

• Original description by Hubert von Luschka (German
anatomist)
• His textbook of 1863, on pages 256-257, he described
two different tubular structures:
The 1st type: intra-mural glands draining into GB lumen,
termed “Luschka crypts”
The 2nd type: a network of microscopic ducts within the
soft tissue surrounding GB
• From a modern perspective, they represented lymphatic
vessels in the majority & in a few have been aberrant BDs
Subvesicle
duct
Schnelldorfer, T., Sarr, M.G. & Adams, D.B. What is the Duct of Luschka?—A Systematic Review. J Gastrointest Surg 16, 656–662 (2012).
https://doi.org/10.1007/s11605-011-1802-5

Schnelldorfer, T., Sarr, M.G. & Adams, D.B. What is the Duct of Luschka?—A Systematic Review. J Gastrointest Surg 16, 656–662 (2012). https://doi.org/10.1007/s11605-011-1802-5
 Type 1 - A segmental/sectoral duct: RPS
duct runs close to GB bed→ main duct
 Type 2 - An accessary duct: arising from
(R) a/p segmental duct→main duct
 Type 3 - Cholecystohepatic duct: the duct
drains into the GB
 Type 4 - A series of minute ducts: end
blindly in the connective tissue of GB bed
Type of subvesicle duct of
Schnelldorfer et al

Cystic artery
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Cystic
artery
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CA: superficial and deep branches. The superficial branch supplies the
gallbladder neck region, the deep branch run towards the body

Cystic
artery
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RHA hump. (a) An artery running alongside the CD is seen on initial
dissection of the hepatocystic triangle. (b) On further dissection, it is
identified as the RHA coursing close to GB (caterpillar hump). A short CA is
seen arising from it and subsequently bifurcating into superficial and deep
branches

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• The concept of ‘Critical View of Safety’ (CVS) was
first introduced by Strasberg in 1995
• 90–95% of patients it is possible to establish CVS
• Almost all cases of BDI, the surgeon did not
establish CVS
Critical View of Safety
(CVS)

1. Hepatocystic triangle cleared of all fibro-
fatty tissue
2. Dissected GB to expose the lower 1/3 of the
cystic plate
3. Demonstration of 2 and only 2 structures i.e.
cystic duct and artery entering the GB
Critical View of Safety
(CVS)
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Calot’s triangle.
Hepatocystic triangle.
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When CVS cannot be achieved
• Cholecystectomy by antegrade (fundus-
first) technique
• Subtotal cholecystectomy
• Cholecystostomy
• Conversion to open cholecystectomy
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• Retain posterior wall and/or a cuff adjacent
to the BD
• Complications: retained stone, postoperative
bile leak (3.1% & 18%)
The key is to ensure
The GB stump: small but adequate enough for safe
closure
CA should be controlled
Subhepatic drain
Subtotal
cholecystectomy
Kapoor, V.K. Mohammad Ibrarullah and SS Sikora: The Safe Laparoscopic Cholecystectomy: An Illustrated Atlas. Indian J Surg
84, 1156–1157 (2022). https://doi.org/10.1007/s12262-021-03155-9

 Avoid excessive lateral and cranial traction, liver at falciform
attachment may tear and bleed
 Do not use excessive cautery during dissection
 Unexpected bleeding: give pressure, identify source & control
 Do not apply clips blindly or do mass cauterization of the tissues
 Bile staining: careful inspection, identify the source
 Suction cannula: blunt dissector, keep the operating field clean
Other safety measures
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Steps of safe laparoscopic
cholecystectomy

Ten steps of safe LC
1. High-definition camera, 30° telescope and a good
camera operator
2. Open pneumoperitoneum and port placement
3. Traction of gallbladder:
a. 10 o’clock position (towards the right
shoulder) of fundus.
b. Lateral and downward traction of Hartman’s
pouch.
4. Identify Rouviere’s sulcus and other landmarks.
5. Open the posterior peritoneum to provide mobility
to the GB and to open the hepatocystic triangle.
6. Define safe area of dissection and achieve the CVS.
7. Time out
a. Review the landmarks and anatomy
b. Confirm the same with the team/senior colleague.
8. Clip and divide the cystic artery and the cystic duct.
9. Dissect GB from the liver bed and place in a pouch.
10. Remove ports and close the fascial layer.
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In each of these steps the surgeon may
encounter different situations
1. Access to the abdomen
2. Gallbladder exposure
3. Dissection of the cystic artery and duct
4. Gallbladder ectomy
5. Gallbladder extraction
☞

1. Access to
the
abdomen
• Obesity: difficulty for access
• Previous surgery/ies: adhesions to the anterior
abdominal wall
• Risks: hollow/viscus/solid injury => aware & keep in
mind
First gesture when entering the abdominal cavity:
exploration to rule out any injury
• Veress/Hasson (closed/open) or optical trocar (high
BMI or previous surgeries)

1. Access to
the
abdomen
Abdominal Access Techniques 77
Section
One
Fig. 5.51: Optical trocar
removing the last telescopic cannula the Trend-
elenburg’s position of the patient is discontinued.
Some surgeon leave some fluid like ringer lactate
inside the abdominal cavity to divert gas away from
sub diaphragmatic space but effect of this is
controversial.
Subdiaphragmatic gas which remains inside is
absorbed completely within 24 to 48 hours after
surgery.
Complications of Access Technique
Improper trocar insertion causes most of the operative
complications of laparoscopic surgery. Examples are
injury to the bowel, major Vessels, bladder, inferior
epigastric vessels and subcutaneous emphysema.
Other complications include thermal injury to the
bowel, abdominal wall contusions, trocar-site
herniation with possible bowel obstruction, and trocar-
site tumor implants. However, the overall incidence of
complications is relatively low (about 2%).
Visceral Injuries
Incidence of Injury of Hollow Viscus
• Small bowel (2.7%)
• Large bowel (0.15%)
• Bladder (0.5%)
Optical trocar
SomeVeressneedlewithinbuiltfiberoptictelescope
is also used for direct visualization at the time of its
introduction but quality of picture is not optimum for
verysafeaccess.
Postoperative Chestand
Shoulder Pain After Laparoscopy
ResidualCO2 leftinsidetheabdominalcavitysometime
cause considerable discomfort like chest pain and
Fig. 5.52: Optical needle
complications of lapa
injury to the bowel,
epigastric vessels a
Other complication
bowel, abdominal
herniation with possi
site tumor implants.
complications is rela
Visceral Injuries
Incidence of Injury o
• Small bowel (2.7
• Large bowel (0.1
• Bladder (0.5%)
• Stomach (0.02%
Solid organs
• Liver
• Spleen.
Vesselinjury
• Inferior epigastric
• Omental
Optical needle
Abdominal Access Techniques 63
S
f peritoneum. Anterior and
s one sheath at the level of
be only one click for rectus.
abdominal wall is selected for
s tip introduced through stab wound Fig. 5.12: Veress needle should be held like a dart
Veress needle
Mishra, R. K. Textbook of practical laparoscopic surgery. JP Medical Ltd, 2013.

2. GB
exposure
• Adhesions: taken down the neighboring organs
• Large liver/or fallen down: fifth-5 mm trocar to
retract
• Biliary fistulas: abnormal connection between GB &
other digestive portions (R colonic explosure,
duodenum, small bowel)=> meticulous dissection,
taking down the trajectory of the communication,
repair the digestive segment
• Mirizzi syndrome

3. Dissection
of cystic
artery, duct
• Difficult Hartmann pouch: impaction of a stone,
difficult to place a grasping forceps
• Anatomic variations

4. GB ectomy
Some tricks
• The puncture, aspiration GB fluid
• Aperture, extraction of stone
• Traction: adequate, cephalad in fundus, caudal in neck
• Partial/subtotal cholecystectomy or cholecystostomy
 Delajenniere technique: leaving a remnant of the GB
 Leaving the GB attached to the liver bed and
cauterizing it
• Fistulae: trajectory should be taken down, suture/very
few times a resection is performed

5. Extraction
• Umbilical or the subcostal trocar (risk of injuring the
epigastric artery)
• Use of a pouch to avoid spillage and/or loss of
stones, represent a medicolegal risk
• Examine the GB specimen: only 1 conduit (the cystic
duct) entering into the GB neck

Special situations
• ACUTE CHOLECYSTITIS
• OVERHANGING LIVER SEGMENTS
• STONE IMPACT
• ABERRANT HEPATIC ARTERY
• MIRIZZI’S SYNDROME
• CHOLECYSTODUODENAL FISTULA
• RESIDUAL GALLBLADDER
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https://doi.org/10.1007/s12262-021-03155-9
ACUTE CHOLECYSTITIS

• Distended GB (mucocele) is decompressed with
suction cannul
• The impacted stone can be felt through the
hepatoduodenal ligament. Attempt to manouevre
the stone out of the CD
• A stone in the CD running posterior to CBD is
technically difficult to access, there is a risk of this
stone being missed and left behind
Stone impacted
in the CD
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Mirizzi syndrome is defined:
• The obstruction of the common hepatic duct
• Extrinsic compression
• Impacted stone in the GB infundibulum or cystic
duct
• Most times they present asymptomatic, the
condition is recognized intraoperatively
=> Increase risk of BDI if the surgeon is not aware
Mirizzi
syndrome

• Pablo Mirizzi (professor of surgery-Argentina)
• First intraoperative cholangiography in 1931,
did not describe Mirizzi syndrome
• The first published paper belongs to Puestow
• Some years later Behrend contributed with a
similar report
Mirizzi
syndrome
MIRIZZI SYNDROME

• McSherry based on ERCP findings, described two
types
• 1989, Csendes proposed a classiﬁcation,
presented 4 types
• 2008 Csendes and Beltrán added types Va & Vb
=>the one described by McSherry is still the most
applicable and used
Mirizzi
syndrome

• McSherry described 2 types:
 Type I: external compression of the BD by a
large stone or stones impacted in the cystic
duct or in the Hartmann pouch
 Type II: cholecystobiliary fistula, caused by
gallstones eroded into the BD
Mirizzi
syndrome

 Type I: external compression of the BD by a
gallstone impacted in the neck of the GB
 Type II: a cholecystobiliary fistula with up to 1/3 of
BD wall erosion
 Type III: a fistula involving 2/3 of the BD wall
 Type IV: complete destruction of BD, its walls
being fused with GB
 Type Va: an uncomplicated fistula
 Type Vb: a cholecystoenteric fistula followed by a
gallstone ileus
Mirizzi
syndrome
Klekowski, J.; Piekarska, A.; Góral, M.; Kozula, M.; Chabowski, M. The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome. Diagnostics 2021, 11, 1660.
https://doi.org/10.3390/ diagnostics11091660

Mirizzi
syndrome
Klekowski, J.; Piekarska, A.; Góral, M.; Kozula, M.; Chabowski, M. The Current Approach to the Diagnosis and Classiﬁcation of Mirizzi
Syndrome. Diagnostics 2021, 11, 1660. https://doi.org/10.3390/ diagnostics11091660

• Hartman’s pouch, hepatocystic triangle: difficult to
access
• Extra ports: retraction of the overhanging liver
• CVS: division of peritoneum, proper retraction,
dissection close to the GB→CVS
• Alternatively, mobilization of GB body, dissection
remaining close to the GB →hepatocystic triangle.
Overhanging
liver
segments
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An aberrant artery of such calibre is likely to be the
right hepatic artery or its segmental division. Hence,
care must be taken to identify, dissect and preserve it.
Aberrant
hepatic artery
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• Challenges: inflammatory fibrosis, adhesions
• Dense adhesion: suspicion of GB-duodenum fistula
• Sharp dissection (blunt dissection→difficult to suture)
• Well conversant in lap. suturing technique
• Duodenal opening: interrupted delayed absorbable
sutures
• “Watertightness”: confirmed by an air leak test
• Conversion
Cholecystoduodenal
fistula
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Residual/recurrent stones in the GB stump:
“reconstituting type” of subtotal-cholecystectomy
• MRCP: define the road map
• Altered anatomy, inflammatory fibrosis, adhesions
• A non-existent/obliterated hepatocystic triangle
• Port placement: facilitate adhesiolysis & suturing
• ICG: defining anatomy
• Prepared to convert
• In specialized center by experienced surgeon
Residual GB
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Residual GB
(a) MRCP showing stone in the GB stump. (b) Port placement: Previous port
p tion 1–4. Current port position 1’–4’. Note that the epigastric port and the
midclavicular ports (2’, 3’) are placed more towards the left to facilitate
adhesiolysis and the dissection of the GB.

• Child A & B cirrhosis can be safely, Child C should be
avoided
• Prone to trauma if excessive retraction
• Landmarks & normal anatomy: get distorted due to
atrophy, hypertrophy of hepatic segments, regenerating
nodules
• Operative bleeding can get exaggerated due to
coagulopathy
Cirrhosis

• EHPVO large collaterals in the hepatoduodenal
ligament and the GB wall, risk of severe bleeding,
restricts dissection CVS
• Dissection of the posterior wall of the GB from the
liver bed can be difficult, with a risk of bleeding due to
collaterals.
Cirrhosis

Use of an ultrasonic
dissector (Harmonic
scalpel) for dissection
and stapler for
transection may help in
overcoming the
difficulty, as in the
present case.
Application of stapler
where the gallbladder
narrows to join the
hepatoduodenal
ligament should
minimize the possibility
of retained stone(s) in
the remnant.
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• Medioposition (midline GB): base of segment IV, right
of the ligamentum teres
• Sinistroposition (left-sided GB): left of the falciform
ligament
Malpositioned
GB

• With/without situs inversus, located to the left of an
anomalous right-sided ligamentum teres
• Base of seg.III, left of ligamentum teres, middle
hepatic vein
• CD: joins to the left/right of the CBD, even left hepatic
duct
• CA crosses in front of the CBD from R->T
• May be atrophy of segment IV
LSGB is associated with a significant risk of BI (4–7.5%),
conversion rates of up to 50%.
Left-sided
gallbladder

Left-sided
gallbladder
 Modify port position +/- a port for retraction
 Hitch the falciform ligament
 The classical posterior dissection
 Dissect by a fundus-first/combined approach,
remaining close to the GB
 ICG cholangiography if anatomy is unclear
 CD is to be divided as the last step
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Left-sided
gallbladder
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Situs inversus
 a “mirror image”
 The use of cholangiography (ICG) is a useful
adjunct, especially in these clinical situations.

Situs inversus

Intraoperative
cholangiography
(IOC)

Recommendation
1. IOC: detect CBD stones, delineate extrahepatic
biliary anatomy in difficult GB, unclear anatomy, BDI is
suspected.
2. Experienced, trained individuals, ensure complete
biliary anatomy is outlined, clearly interpreted.
3. If facilities of FC are available, be preferred over IOC
4. IOC & FC: limitations in acute cholecystitis, obesity
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• Recommended routinely for the detection of BD
stone/s and delineation of biliary anatomy
• Technique:
 dissection of CD
 ligation or clip of proximal GB
 cannulation of CD
 injection of the radio opaque dye, fluoroscopy
 imaging
Intraoperative
cholangiography
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(a) After dissection of the CD,
ligature is placed proximally
(towards the GB) & ductotomy
is made on the CD. (b)
Ductotomy is being probed
with a ‘right angle’ clamp
(c) CD is cannulated with a 5F
ureteric catheter. (d) Catheter is
secured and cholangiogram
performed. Inset –
Cholangiogram delineating the
CHD, right and left hepatic
ducts and the CBD with no
filling defect. Dye is seen in the
duodenum
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Intraoperative
cholangiography
A normal IOC:
• The contrast is visualized in both the (R) hepatic duct
(anterior, posterior) and the (L) intrahepatic duct above their
confluence
• Lack of filling defects in the CBD
• Free flow of contrast into the duodenum
• Thermal injuries: energy sources (electrocautery, ultrasonic
devices); electrocautery close to the titanium clips

Limitations of IOC
a. Facility: high-resolution fluoroscopy equipment,
expertise
b. Additional operating time and cost
c. IOC cannot be performed where the CD is
blocked
d. Incorrect interpretation of the biliary anatomy on
cholangiograms ≈57%
e. Attempts at performing IOC may lead to a BDI
Intraoperative
cholangiography
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Fluorescent cholangiography
• Administration of indocyanine green (ICG)
intravenously, 0.05 mg/kg
• 30 minutes–6 hours prior to cholecystectomy
• Fluorescence and imaging are achieved through
a dedicated system of near infra-red light detected
by a special lens system.
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• Defines the extrahepatic biliary system with
good consistency; CD 96.2%, CHD 78.1%, CBD
72%, CD-CHD junction 86%
• Images are obtained in real time, can be
repeated during surgery and various stages of
dissection
Fluorescent
cholangiography
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• Visualization rates of structures increase after
the dissection, especially of the CD and CD-CHD
junction
• Due to limited penetration of near infra-red
light => limited in obese patients and in acute
cholecystitis with severe local inflammation.
Fluorescent
cholangiography
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Advantages of FC
1. Ease of conducting the study.
2. Quicker and cheaper with a very steep
learning curve.
3. Opportunity of dynamic real time assessment
during all phases of dissection.
4. Non-invasive, no radiation exposure and
useful, even in a blocked CD.
5. No possibility of procedure-related BDI unlike
the conventional IOC.
Fluorescent
cholangiography
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Troubleshooting during
Laparoscopic Cholecystectomy
• Bleeding
• Bile leak
• Gallbladder perforation
• Cystic duct injury
• Common bile duct injury
• Subvessicle duct
• Stone spillage
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Sabiston: textbook of surgery: the biological basis of modern surgical practice, twenty first edition Copyright © 2022, Elsevier Inc. All rights reserved
Strasberg classification of postoperative Bdstric tures
(A) Injury to small ducts with a leak in the duct of Luschka or the
CD. (B) Injury to a sectoral duct, causing obstruction of portion of
the biliary system. (C) Injury to a sectoral duct with bile leak; leak
from a duct not continuous with the biliary system. (D) Lateral
injury to the extrahepatic BD.
(E1) Bismuth type 1: injury more than 2 cm from the confluence
(E2) Bismuth type 2: injury less than 2 cm from the confluence
(E3) Bismuth type 3: injury at the confluence; confluence intact
(E4) Bismuth type 4: destruction of the biliary confluence
(E5) Complete occlusion of all bile ducts, including sectoral ducts

Perception error: hepatocystic triangle is fat-laden,
obscuring the anatomy. CBD in alignment with
infundibulum (black dotted line) can be mistaken as
CD, leads to dissection on the medial side of the CBD
(dotted straight line and arrow), BD vulnerable to
injury. White dotted curved line (arrow) marks the
correct site of dissection. The presence of the
duodenum close to the ‘apparent cystic duct’ should
also alert the surgeon about the possible error
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Major biliovascular injury: ‘near miss’
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Transected common bile duct
MRCP showing missing bile duct
segment and biloma & Bismuth
Type II stricture in the same
patient 5 months later.
https://doi.org/10.1007/s12262-021-03155-9

Transected CBD & vascular injury
Posterior view – the dissected
segment is much below the plane
of Rouviere’s sulcus and the R4U
line. Note the clipped right hepatic
artery.
The double lumen in the clipped
end
The dissection commences medial
to presumed infundibulum (dotted
area) and below the R4U line
(dashed black line)
https://doi.org/10.1007/s12262-021-03155-9

Complex biliovascular injury
The resultant complex stricture (Bismuth
Type V) on MRCP three months later. The
transected duct at the hilum, separated
right anterior, posterior and left hepatic
ducts.

Prevention of Biliary Duct
Injuries (BDI)
The factors leading to injury may be grouped in the following:
1. Patient and disease
2. Operating room environment: personnel, supplies,
devices, infrastructure
3. Procedure: design error-proof procedures
4. Human factors

Detailed
training
program
Training to surpass difficulties when no longer under
strict supervision
 In-depth knowledge: basics of anatomy, surgical
techniques, cal alternatives
 A standard error-proof procedure
 Technique-related skills: honed in virtual or ex vivo
simulation models

Detailed
training
program
 Nontechnique-related skills, include:
o Ability to control the environment
o Practical & effectiveness of leadership of a surgical
team
o Proper personal behavior, calm and appropriate
response to difficult, inconvenient situations
o Avoidance of dangerous situations
o Attention to warning signs
o Willingness to call for help

Achieve a safe cholecystectomy
(TOKYO GUIDELINE 2018)
• If the GB is distended, interferes with view:
decompressed by needle aspiration
• Effective retraction to develop a plane in the Calot
triangle
• Starting dissection from the posterior leaf of the
peritoneum, above RS
• Maintaining the plane of dissection on the GB surface

• Dissecting the lower part of the GB bed (at least one-
third) to obtain the CVS
• Creating the CVS
For persistent hemorrhage, hemostasis by compression,
avoiding excessive use of electrocautery or clipping.
Achieve a safe cholecystectomy
(TOKYO GUIDELINE 2018)

SOCIETY OF AMERICAN GASTROINTESTINAL &
ENDOSCOPIC SURGEONS (SAGES)
RECOMMENDATIONS
1. Use the ‘Critical View of Safety’ (CVS)
2. Understand the potential for aberrant anatomy
3. Use of cholangiography/other methods to
image the biliary tree intraoperatively
4. Intraoperative momentary pause prior to
clipping, cutting or transecting any ductal
structures
5. Recognize when approaching a zone of
significant risk, halt the dissection before
entering the zone. Finish the operation by a
safe method other than cholecystectomy if
conditions around the GB are too dangerous
6. Get help from another surgeon when the
dissection or conditions are difficult

Final remark
Some tips to take into account:
– Never perform a LC without a skilled surgeon close by
– Beware of the easy GB
– Slow down, take your time
– Knowledge is power, conversion can be the salvation!

Final remark
Some tips to take into account:
– Do not repair a BDI (unless you have performed
at least 25 hepaticojejunostomies)
– Do not ignore postoperative complaints (pain,
jaundice, major abdominal discomfort, fever)

Final remark
Other options when confronted with a difficult LC
– Percutaneous cholecystostomy: the risk was identified
preoperatively, patient is a poor surgical candidate
– Intraoperative cholangiography, may aid in identifying
an BDI & solve it
– A subtotal or partial cholecystectomy
– Ask for help
– Conversion to an open procedure

REFERENCES
1. Kapoor, V.K. Mohammad Ibrarullah and SS Sikora: The Safe Laparoscopic Cholecystectomy: An
Illustrated Atlas. Indian J Surg 84, 1156–1157 (2022). https://doi.org/10.1007/s12262-021-03155-9.
2. Podda, Mauro & Virdis, Francesco & Tejedor, Patricia & Pellino, Gianluca & Di Saverio, Salomone.
2021. Gastrointestinal Surgical Emergencies. The American College of Surgeons - Management of
Acute Diverticulitis. Difficult Cholecystectomy: How to Prevent Biliary Injuries.
3. Klekowski, J., Piekarska, A., Góral, M., Kozula, M., & Chabowski, M. (2021). The Current Approach to
the Diagnosis and Classification of Mirizzi Syndrome. Diagnostics (Basel, Switzerland), 11(9), 1660.
https://doi.org/10.3390/diagnostics11091660.
4. Spanos CP, Spanos MP. Subvesical bile duct and the importance of the critical view of safety:
Report of a case. Int J Surg Case Rep. 2019;60:13-15. doi: 10.1016/j.ijscr.2019.05.040.
5. Mishra, R. K. Textbook of practical laparoscopic surgery. JP Medical Ltd, 2013.

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