Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

Abstract

Background Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI. Methods Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidencebased recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus. Results Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team. Conclusion These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure

“…It would seem unlikely that surgeons not understanding this simple concept or that the lack of photographic documentation of the CVS is to blame for biliary injuries. A multi-society consensus conference on prevention of bile duct injury during cholecystectomy suggested that no direct comparative evidence was identified to support the critical view of safety (CVS) over other methods for anatomic identification [16]. It concluded that there is no substantial evidence that reasonable efforts to achieve the CVS have been associated with undesirable effects.…”

Laparoscopic Ultrasound and Safe Navigation Around the Shrunken Gallbladder

“…BDI rate has plateaued over the last time and is close to the open cholecystectomy era ranging between 0.15% and 0.36%. 6,7 The most common cause of BDI is misidentification of the visualized anatomical structures. Noteworthy is also surgeon skill and anatomical variations in the hepatocystic triangle.…”

“…There are no recommendations if the conversion limits the risk or severity of BDI during difficult laparoscopic cholecystectomy. 7 It does not always provide a better view of the anatomy and may be associated with a higher risk of BDI and VBI. The younger generation of surgeons is not familiar with this technique.…”

“…Still, no recommendations based on the available data were made. 7 There are also no recommendations on relaying on NIRF-C, which is not a substitute for the right dissection and identification technique. 7 LUS with appropriate experience and training may be used as an alternative to IOC.…”

“…7 There are also no recommendations on relaying on NIRF-C, which is not a substitute for the right dissection and identification technique. 7 LUS with appropriate experience and training may be used as an alternative to IOC. 7 Photo or video documentation, including LUS reports, may also be necessary for teaching, quality, and litigation purposes.…”