Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions

Abstract

BackgroundBile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness.MethodPubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy.ResultsNine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61–0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques.ConclusionsThe critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety.

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

“…Despite variation on opinions about the routine or selective use of IOC, it has demonstrated a reduction in the incidence of major BDI and expeditiously identifies insults at the time of surgery [2,13,52,59,[70][71][72][73]. Archer et al [13] reported that routine use of IOC increased detection of BDI from 45 % to 85 %, which is similar to the increased detection described by Ludwig et al [9] from 45 % to 90 %.…”

Intraoperative ultrasonography of the biliary tract using saline as a contrast agent: a fast and accurate technique to identify complex biliary anatomy

“…[5][6][7][8][9][10]15 The contrast leak in the surgical field may result in poor image quality, especially when small ducts are being evaluated. Also, owing to the 2D nature of the image, accurate identification of 2 overlapping liver segments is very diffi cult.…”

Laparoscopic Intraoperative Cholangiography Interpretation by Surgeons versus Radiologists, A Comparative Study and Review of 200 Cholangiographies

“…Special attention should be paid to the learning curve for interpreting IOC, as some studies report high proportions of incorrectly interpreted cholangiograms. For example, Way et al [7] demonstrated that 34/43 (79%) routine cholangiograms that showed bile duct injury were incorrectly interpreted [1]. Woods et al reported 53 patients, Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six [8].…”

“…LIOC is the most frequently applied technique for intraoperative assessment of the biliary anatomy [1]. LIOC is a dynamic procedure; the only real advantage to the surgeon is being able to view the IOC, and specifically the character and movement of any filling defect in real-time, which aids the interpretation of whether there is a stone or air bubble.…”