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

Abstract

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 identificationthe "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 cholecystectomyand 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.

Transillumination of Calot’s Triangle on Laparoscopic Cholecystectomy: A Feasible Approach to Achieve a Critical View of Safety

“…Since the introduction of the CVS, many studies have validated its feasibility and utility in diminishing BDI, with some series even reporting zero incidences of BDI [7]. Eighty percent of BDIs occur while attempting a CVS [8], and Strasberg et al published a three-step roadmap for avoiding BDI that consists of the following sequence [9]. First, surgeons should try to get a secure, anatomical identification of key structures.…”

“…When this is not possible, the surgeon should not attempt a total cholecystectomy ("inflection point"). For finishing the operation safely, Strasberg's last point includes conversion or bail out procedures such as cholecystostomy, subtotal cholecystectomy, either fenestrated or reconstituting, conversion, or even concluding the procedure and referring the patient appropriately [9].…”

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal

“…is can be attributed to the "culture of safe cholecystectomy," by adopting critical view of safety, Rouviere's sulcus as a landmark for initiation of dissection, bail-out options or early conversion in difficult cholecystectomy, time-out and in vicinity "colleaguography" before clipping, and extravigilance in an academic centre for the risk and consequences of bile duct injury [4,[12][13][14].…”

Looking for the best practice for acute cholecystitis

“…Factors surrounding surgeons should be considered important as misidentification of the anatomy can lead to major BDI; a surgeon's desire to complete a total cholecystectomy might also have an effect. Strasberg recommends that surgeons abandon their attempt to carry out a complete cholecystectomy—and instead conduct a “bail out” procedure—if they cannot clearly identify anatomical structures . However, the definitive indication for “bail out surgery” remains unclear.…”