Safe laparoscopic cholecystectomy

Abstract

The February 2004 issue of Surgical Endoscopy published an article by the Gruppo Laparoscopico Romano entitled ‘‘Bile Duct Injuries During Laparoscopic Cholecystectomy: A 1994–2001 Audit on 13,718 Operations in the Area of Rome.’’ The authors analyze different relevant factors which may influence or participate in the incidence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). The study correctly showed that the 0 optic probably is not suitable for LC because 29 BDIs occurred when this type of instrument was used, compared with 6 BDIs when a 30 optic was used. We, however, note an unusual statement made by the authors in the Results section, namely that the French technique resulted in 27 (81.8%) of the recorded BDIs, whereas the remaining 6 (18.2%) occurred with use of the American technique. The readers are left without any further explanation or conclusion. This statement could, however, mislead young surgeons to believe that LC performed using the French technique carries a fourfold higher rate of BDIs than the American technique. To avoid such a misinterpretation, we think the authors should have informed the readers about how many LCs were performed using each of the two techniques. A short calculation confirms that the French technique is the more widely used in the Rome area. With this technique, the tissue in the triangle of Calot is dissected primarily to visualize the cystic duct and the cystic artery, and to form the first window between these two anatomic structures. The next step is to form a second window by careful dissection between the cystic artery and the gallbladder liver bed. After the anatomy of the triangle of Calot has been assesses carefully from both the anterior and posterior aspects of the gallbladder (‘‘critical view’’), clips can be placed on each of the two structures, which then can be divided safely. Laparoscopic cholecystectomy using the French technique is best adjusted, in our experience as well as that of others, to minimize the risk of causing a BDI. How many LCs have been performed by surgeons in Rome and its provinces using the French technique? According to the authors, the incidence of BDIs was unchanged during the 8-year period (i.e., 0.24%). Whereas 27 French BDIs at a rate of 0.24% represent 11,250 LCs, 6 American BDIs at the same 0.24% rate represent 2,500 LCs. Commendable surgical skill contributes to the high percentage (82%) of LCs performed using the French technique in the Rome area, whereas only 18% were performed using the American technique. In any case, the French operative technique, which ensures the performance of safe LCs, is used by the majority of surgeons in the area of Rome and its provinces. In conclusion, the study showed that there was no difference in the incidence of BDIs between the two techniques.