A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review.

Authors:
Steven M Strasberg
Steven M Strasberg
Washington University School of Medicine
United States

J Hepatobiliary Pancreat Sci 2019 Apr;26(4):123-127

Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, St. Louis, MO, 63110, USA.

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification - the "inflection point"; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy - and instead to "bail-out". This "inflection point" is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.

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http://dx.doi.org/10.1002/jhbp.616DOI Listing
April 2019
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(Supplied by CrossRef)
An analysis of the problem of biliary injury during laparoscopic cholecystectomy
Strasberg SM et al.
J Am Coll Surg 1995
Operative strategy can reduce the incidence of major bile duct injury in laparoscopic cholecystectomy
Yegiyants S et al.
Am Surg 2008

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