Bile Duct Injury In Cholecystectomy Research Articles

BN SO40 - Increasing incidence of medicolegal claims in the NHS for bile duct injury in spite of 30 years of experience and training

Abstract Background Bile duct injury (BDI) in cholecystectomy is the most commonly recognised complication occurring in 0.5-1.4% of cases and is associated with significant morbidity and mortality. Despite the increasing number of cholecystectomies and falling number of bile duct injuries due to both surgical experience and recognition of the issue, there appears to be increasing number of payouts by NHS England. We investigated the trend in claims, their underlying cause, stage in procedure where they occurred in the past 20 years to identify areas where improvements could be made, for better patient outcomes and to reduce the medicolegal burden to the NHS. Method Data was obtained following a freedom of information request from NHS Resolution UK for cases of bile duct injury. Data analysis was performed on years 2001-2021 to examine the number of claims, their underlying cause and stage in procedure where they occurred as well as average damages awarded and cost to the NHS. Results In 2001 there were 11 claims made (costing £644,000) which rose to 28 in 2021 (costing £7,424,000). 400 claims were successful out if 508. The commonest being intraoperative error (49%) followed by operator error (11%) and delay in treatment (8%). The most expensive type of claim arose from intraoperative complications costing a total of £42,836,000 over the period. Pre-operative delays and inadequate patient consent cost the NHS £7,236,000, whilst delays in recognition of BDI cost £8,000,000 between 2001 and 2021. Conclusion Although settled cases of BDI have risen in the last 20 years despite improvement in training and techniques of cholecystectomy, they remain significantly below the anticipated numbers. Prompt recognition of anatomy and intraoperative complication as well as effective post-op management are essential for better patient outcomes and maintaining this low claim rate. Surgeon training within the NHS is crucial but appropriate case selection is the key to patient safety. Laparoscopic cholecystectomy can be a complex operation, worsened by delays in treatment , requires an experienced UGI surgeon or supervision by a consultant and never considered simple or routine operation.

Avoidance of bile duct injury in laparoscopic cholecystectomy with feasible intraoperative resources: A cohort study.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR.

Bile Duct Injury in Laparoscopic Cholecystectomy; A Multi Centre Experience

Background: Laparoscopic cholecystectomy (LC), a minimally invasive gallbladder removal surgery, has revolutionized the field with benefits like quicker recovery. However, it is not without risks, and bile duct injury (BDI) is a severe but rare complication. BDI incidence during LC varies (0.4%-0.9%), with potentially life-threatening consequences. Surgeon experience, intraoperative cholangiography, and careful handling are crucial in preventing and managing BDIs. Aim of the study: This study aims to present and analyze a Multi centre experience regarding the management of these bile duct injuries in LC. Methods: This retrospective study, conducted at UAE medical institutions from 2014 to 2024, analyzed 2400 Laparoscopic Cholecystectomy surgeries over ten years. Out of 18 patients, thirteen patients were treated with ERCP, while five required additional surgery. Inclusion criteria involved patients aged 30 to 70+, of both genders, with BDIs. Exclusion criteria included minor BDIs and comorbidities. Two diagnostic techniques, including intraoperative cholangiography and postoperative assessments, identified BDIs. Treatment varied based on Strasberg classification, involving suturing, ERCP, stent placement, and Roux-en-Y hepaticojejunostomy. Data analysis employed SPSS, presenting results through tables and graphs with statistical parameters. Result: The study focused on Laparoscopic Cholecystectomy-related Bile Duct Injuries (BDI), with a cohort primarily aged 51-70 (66.67%). This age group showed higher susceptibility to BDI. The average participant age was 55.21±12.54 years, with a male majority (55.56%). Among 18 Endoscopic Retrograde Cholangiopancreatography (ERCP) cases, five had BDI, diagnosed intra/postoperatively. Two patients with clinical symptoms had postoperative diagnosis through Percutaneous Transhepatic Cholangiography (PTC). Strasberg classification revealed 60% Type A injuries; Types E1 and E2 each constituted 20%. Treatment modalities varied, with ERCP for Type A injuries (60%) and Roux-en-Y Hepaticojejunostomy (RYHJ) for Types E1 and E2. Conclusion: ERCP is a valuable method for diagnosing and managing Bile Duct Injuries (BDIs). The predominant type of BDIs, specifically Type A, is typically diagnosed after surgery. ERCP demonstrates its efficacy in addressing the majority of Strasberg Type A BDIs. In substantial and intricate BDIs, the Roux-en-Y Hepaticojejunostomy is a secure and efficient approach.

Predective Factors of Common Bile Duct Injury in Laparoscopic Cholecystectomy

Predective Factors of Common Bile Duct Injury in Laparoscopic Cholecystectomy

Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm.

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Is the Safe Cholecystectomy Technique Really Safe?

Aim: This study aims to present the results of a single surgeon's experience to demonstrate the effectiveness of the 'Critical View of Safety' (CVS) technique in preventing bile duct injuries in clinical practice. 
 Method: We retrospectively reviewed the records of 899 patients who underwent cholecystectomy using the CVS technique performed by a single surgeon at the Sivas Cumhuriyet University Hospital General Surgery Department between 2018 and 2023. Ethical approval for the study was obtained. Cholecystectomy cases were scanned retrospectively. The patients' age, gender, drain placement, surgery indications, and reason for switching to open cholecystectomy were recorded. 
 Results: Among the 899 patients reviewed, 312 were male (34.70%), and 587 were female (65.30%). The average age was 55.10 for males and 51,65 for females. It was determined that 7(0.77%), cases converted to open cholecystectomy. The most common indication for cholecystectomy was elective gallbladder stone removal, accounting for 47.05% of cases. No major bile duct injuries were detected..
 Conclusions: The safe cholecystectomy technique can be safely applied to avoid bile duct injuries in laparoscopic cholecystectomy.

Presentation Of Post Cholecystectomy Bile Duct Injuries In A Tertiary Care Hospital

Introduction:The occurrence of iatrogenic bile duct injuries is few, however potentially linked to life-threatening complications, particularly following the advent of laparoscopic cholecystectomy. Aims &Objectives: To evaluate the presentation of post-cholecystectomy bile duct injuries in a tertiary care hospital. Place and Duration of Study: This study was done in the Department of General Surgery at Combined Military Hospital Rawalpindi from Nov 2020 to Dec 2021. Material &Methods: This cross-sectional study was conducted on 15 subjects with post-cholecystectomy bile duct injuries.All the patients who presented to the emergency department and outdoor were included in the study and had post-cholecystectomy CBD injuries. Laparoscopic and open BDI were classified according to Strasberg classification. In descriptive statistics, mean, and standard deviation was used, and in qualitative analysis, frequency and percentages were calculated with the help of the SPSS 23 version, a p-value of? 0.05 was considered significant. Results: In our study, 5 (33.3 %) males and 10 (66.7 %) were females, with a mean age of 47.27 ± 4.79. The presentation on the admission of patients was as follows, 3 (20.0 %) patients had biloma, 4 (26.7 %) had jaundice, 2 (13.3 %) had abdominal pain, 1 (6.7 %) had external biliary fistula, 3 (20.0 %) had Biliary peritonitis and 2 (13.3 %) had a fever. Conclusion: The most common consequence of cholecystectomy was complete resolution, but bile leak and major duct damage cause considerable morbidity, death, and healthcare expenditures. Better outcome was achieved when a nonprimary and skilled hepatobiliary surgeon repaired severe bile duct damage.

Evaluating the Impact of Surgical Occurrence of Bile Duct Injuries in Laparoscopic Cholecystectomy- A Retrospective Observational study

Background: Laparoscopic cholecystectomy (LC) is the gold standard for treating gallstone disease, offering numerous benefits over traditional open cholecystectomy. However, bile duct injuries (BDIs) are a significant complication, contributing to substantial morbidity and mortality. This study aims to evaluate the incidence, causes, risk factors, treatments, and outcomes of BDIs in laparoscopic cholecystectomy in Bangladesh. Material & Methods: This retrospective observational study was conducted at the Department of Hepatobiliary, Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University, Al-Manar Hospital Limited, and Abeer General Hospital, Dhaka, Bangladesh. During this period, a total of 1255 complete hospital records of laparoscopic cholecystectomy conducted over the last 5 years at the study hospital were selected for the study following inclusion and exclusion criteria. Results: Out of laparoscopic cholecystectomy cases, 20 (1.64%) patients experienced BDIs. The most common cause of BDI was clipping or transection of the duct (33.33%), followed by mistaken anatomy (22.22%) and ischemic injury due to clip (18.52%). Acute cholecystitis was the most prevalent risk factor (37.04%). Standard laparoscopic cholecystectomy was performed in 83.33% of BDI cases, with the remaining 16.67% undergoing single-incision laparoscopic cholecystectomy. The majority of patients (74.07%) had no complications after BDI treatment, while 18.52% experienced minor complications, 5.56% had major complications, and 1.85% resulted in mortality. Conclusion: This study highlights the importance of meticulous surgical technique, early recognition, and appropriate management of bile duct injuries in laparoscopic cholecystectomy. By continually refining our understanding of the factors contributing to BDIs and implementing evidence-based strategies to prevent and manage this complication, we can optimize patient outcomes and ensure the highest standards of care in laparoscopic cholecystectomy.

Concomitant vascular and bile duct injury in cholecystectomy

Aim . To evaluate the immediate and long-term outcomes in surgical treatment of concomitant vascular and bile duct injuries. Materials and methods. 157 patients with cicatricial strictures of the bile ducts were observed from 2012 to 2021. According to the Strasberg-Bismuth classification of bile ducts injuries, type E1-2 was detected in 22 patients, type E3 – in 77, and E4 – in 56 patients. 141 patients underwent cholecystectomy and five of them (4%) were detected with concomitant vascular and bile duct injury. Results . Hemihepatectomy with bile duct reconstruction was performed in two cases; three patients underwent bile duct reconstruction only. One patient died in the early postoperative period, three patients continue treatment. In one case, treatment was successfully completed. Conclusion . Concomitant vascular and bile duct injury is a rare and severe complication of cholecystectomy. Success of treatment depends on the level and character of the vessels and bile duct damage, and treatment strategy.

Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach

Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach. Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth. Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238). Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.

Analysis of risk factors for bile duct injury in laparoscopic cholecystectomy in China: A systematic review and meta-analysis.

Background:To explore the risk factors of bile duct injury in laparoscopic cholecystectomy (LC) in China through meta-analysis.Methods:The study commenced with a search and selection of case–control studies on the risk factors for bile duct injury in LC in China using the following databases: PubMed, EMBASE, ScienceNet.cn, CNKI, Wanfang Data, and VIP. Data were extracted from the collected documents independently by 2 researchers, following which a meta-analysis of these data was performed using Revman 5.3.Results:The compilation of all data from a total of 19 case–control studies revealed that among 41,044 patients, 458 patients experienced bile duct injury in LC, accounting for the incidence rate of 1.12% for bile duct injury. The revealed risk factors for bile duct injury were age (≥40 years) (odds ratio [OR] = 6.23, 95% CI [95% confidence interval]: 3.42–11.33, P < .001), abnormal preoperative liver function (OR = 2.01, 95% CI: 1.50–2.70, P < .001), acute and subacute inflammation of gallbladder (OR = 8.35, 95% CI: 5.32–13.10, P < .001; OR = 4.26, 95% CI: 2.73–6.65, P < .001), thickening of gallbladder wall (≥4 mm) (OR = 3.18, 95% CI: 2.34–4.34, P < .001), cholecystolithiasis complicated with effusion (OR = 3.05, 95% CI: 1.39–6.71, P = .006), and the anatomic variations of the gallbladder triangle (OR = 11.82, 95% CI: 6.32–22.09, P < .001). However, the factors of gender and overweight (body mass index ≥ 25 kg/m2) were not significantly correlated with bile duct injury in LC.Conclusions:In the present study, age (≥40 years), abnormal preoperative liver function, gallbladder wall thickening, acute and subacute inflammation of the gallbladder, cholecystolithiasis complicated with effusion, and anatomic variations of the gallbladder triangle were found to be closely associated with bile duct injury in LC.

Robotic assisted cholecystectomy – A retrospective cohort study of experience of 106 first robotic cholecystectomies in versius robotic platform

IntroductionLaparoscopic cholecystectomy is currently the standard of care for symptomatic cholelithiasis as well as for chronic and acute cholecystitis. The incidence of bile duct injury in laparoscopic cholecystectomy is still higher than that in open surgery. Surgical robots aim to bridge this gap. With the greater availability of surgical robots and cheaper alternatives to the Da Vinci system, surgeons can take advantage of the better manoeuvrability and better vision that a surgical robot offers. This is likely to make robotic assisted cholecystectomy a very safe option. Here, we present our early data on the robotic procedures performed by the Versius robotic system by CMR (Cambridge Medical Robotics). MethodsIt is a retrospective study, with data collected from our prospectively maintained database at Swagat Super Speciality Surgical Institute and NH, maintained collectively by CMR and our surgical residents. The first consecutive 106 planned robotic cholecystectomies that were performed by a single surgeon were included in the study. ResultsOut of 106 serial planned robotic assisted cholecystectomies (101 robotic assisted cholecystectomies + 5 combined with other procedures), no bile duct injury was reported, with a mean console time of 54.16 min and a mean setup time of 9.29 min. One procedure had to be converted to open for malignancy, and another patient had to be converted to laparoscopy due to dense adhesions with the duodenum. Three chronic liver disease (CLD) patients underwent partial cholecystectomy. A total of 70.75% of patients had no pain – visual analogy scale (VAS) pain score of 0 at POD 1 with minimal blood loss in most of the procedures. No learning curve for robotic assisted cholecystectomy was seen. ConclusionAlthough robotic assisted cholecystectomy was mostly chosen for patients in whom difficult cholecystectomy was clinically anticipated, it fared quite well. The learning curve was essentially non-existent. Robotic assisted cholecystectomy is a safe and feasible option in both simple and difficult cases of gallbladder disease.

Post cholecystectomy bile duct injury: a surgeon’s nightmare

Bile duct injury constitutes a major proportion of morbidity associated with cholecystectomy (laparoscopic&gt;open). It has a lot of impact on patient health and subsequent medico-legal repercussions. Anatomical aberrations in the Calot's triangle anatomy is more common than meets the eye. A thorough understanding of anatomy, identification of the variant structures, Use of intraoperative cholangiogram and low threshold for conversion to open procedure could prove life-saving in many cases. Optimal timing of intervention has to be planned once the type of injury is identified. Minor leaks are usually managed with endoscopic interventions. More proximal leaks and complete transaction of bile duct usually require Roux En Y hepaticojejunostomy. The principal is to ensure complete drainage of all segments and prevention of sepsis. More grave scenarios like concomitant vascular injury, segmental atrophy and secondary biliary cirrhosis require referral to a tertiary centre and subsequent multidisciplinary approach. The aim of the study was to establish the true incidence, classification and management of bile duct injuries that could be life - saving in a few cases and career- saving in many others.

The Critical View of Safety in Laparoscopic Cholecystectomy: User Trends Among Residents and Consultants.

The Critical View of Safety (CVS) aims at preventing bile duct injuries (BDIs) in laparoscopic cholecystectomy (LCC). This study investigated CVS utilization among surgeons. Photos from LCCs were scored for satisfactory CVS. Rates of satisfactory CVS, BDIs, and postoperative complications among residents and consultants were compared. A lecture on CVS was given halfway through the study. The study comprised 1532 patients. Residents had higher rates of satisfactory CVS in elective LCCs compared with consultants (34.9% vs. 23.0%, P <0.001), but not in emergency LCCs (18.4% vs. 15.0%, P =0.252). No significant differences in BDIs or postoperative complications emerged between residents and consultants. After the lecture, elective LCCs were photographed more frequently (80.3% vs. 74.0%, P =0.032), but rates of satisfactory CVS, BDIs, and postoperative complications remained unchanged. Utilization of CVS can be affected by a single lecture but affecting rates of satisfactory CVS may require stronger interventions.

The significance of preoperative cholangiogram for avoiding bile duct injury in laparoscopic cholecystectomy

The significance of preoperative cholangiogram for avoiding bile duct injury in laparoscopic cholecystectomy

The significance of preoperative cholangiography for avoiding bile duct injury in laparoscopic cholecystectomy

The significance of preoperative cholangiography for avoiding bile duct injury in laparoscopic cholecystectomy

The Result of the Critical View of Safety Timeout Technique in Prevention of Bile Duct Injury in Laparoscopic Cholecystectomy: A Retrospective Study at a Large Community Teaching Hospital

Background: Laparoscopic cholecystectomy (LC) is the standard treatment for cholelithiasis. However, despite improvements in technology and implementation of a safer approach, such as the critical view of safety (CVS) technique, the risk of bile duct injury (BDI) remains an issue. Objective: To review LC cases at a large community hospital for BDIs and compare BDI rates between conventional technique and CVS timeout approaches. The authors hypothesized that there would be lower BDI rates in the CVS timeout group. Materials and Methods: The authors conducted a retrospective study of 1,033 consecutive patients that underwent LC at the authors’ institution between November 2015 and November 2018. Based on the timeout document and operative reports, the authors classified patients into CVS timeout and no CVS (noCVS) timeout groups and compared the BDI rates and other relevant clinical outcomes. Results: Among the 1,033 patients, 635 and 398 patients were in the noCVS timeout and CVS timeout groups, respectively. There was no significant difference in the incidence of BDI between the two groups at 1.1% versus 1.8%, respectively (p=0.375). The CVS group exhibited less preemptive conversion to open cholecystectomy, lower incidence of uncontrolled intraoperative bleeding, shorter operative time, and shorter length of hospital stay than the noCVS group. In multivariate regression analysis, operative time of more than 90 minutes was the significant independent risk factor associated with BDI, while previous biliary inflammation was marginally associated with BDI. Conclusion: The present study failed to demonstrate the beneficial effect of CVS timeout in preventing the development of BDI. The reasons could be attributed to surgeons’ competency with their varying skills and experience, the occurrence of injury before timeout, the case selection biases, or the wrong CVS identification. Further review of the actual surgical videos may offer more clarity into the unexpected outcome. Keywords: Bile duct injuries; Critical view of safety; Infundibular techniques; Laparoscopic cholecystectomy

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury

Introduction: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality and can be a devastating complication for a General Surgeon. We introduce a novel individualized surgical coaching program for surgeons who recently experienced a bile duct injury in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons’ experiences in the coaching program. Study design: Six General Surgeons who experienced a bile duct injury at an emergency laparoscopic cholecystectomy participated in a one-on-one coaching session with an Hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. Results: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-one sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, non-judgmental relationship is critical in establishing positive coaching experiences. Conclusion: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

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Introduction: Major bile duct injury in laparoscopic cholecystectomy results in morbidity and needs further management, which adds to the increased cost of treatment. However, some studies have shown that by defining critical view of safety and seeing the relationship of Rouviere's sulcus with other structures, and minimal use of diathermy in Calot's triangle, we can bring down complications further close to zero percent. We wanted to see that such a low bile duct injury rate is achievable at every center by routinely following these steps. We retrospectively reviewed the database of patients who had undergone elective laparoscopic cholecystectomy (LC) in three years and evaluated the rate of bile duct injury and other complications. Methods: We reviewed our database for patients and did a retrospective analysis on patients who were diagnosed with symptomatic cholelithiasis or chronic cholecystitis, and have undergone LC in our centre from January 2017 to December 2019. Patients less than 15 years of age, acute cholecystitis, and laparoscopic cholecystectomy combined with common bile duct exploration were excluded. We calculated the incidence of biliary injury. The secondary outcomes looked at were Veress needle or pneumoperitoneum-related complications, port site bleeding, intra-abdominal bleeding, bowel injury, liver injury, wound infection, and early port site hernia. Results: LC was performed in 642 patients. In this study, there was no bile duct injury. Two patients (0.31%) had minor bile leak which resolved without any intervention within a week. Three (0.46%) patients developed port site infection, which responded to regular dressing and oral antibiotic therapy. Conclusion: The effectiveness of these steps should make their use mandatory in every center to reduce bile duct injury.

The Efficacy of Preoperative Cholangiography for Avoiding Bile Duct Injury in Laparoscopic Cholecystectomy

Introduction: Despite the development of surgical technique, iatrogenic bile duct injury (BDI) is one of the most dreadful complication of laparoscopic cholecystectomy (LC). Evidence has suggested that visual misperception accounts for 97% of BDI and aberrant right posterior sectoral hepatic duct (aPHD) is the most common and most vulnerable to BDI. This study aimed to analyze the frequency of each type of variation and efficacy of preoperative imaging. Method: From March 1, 2017 to February 28, 2021, 1477 patients who underwent cholecystectomy at Wonkwang University Hospital were enrolled. Among them, images of the 1429 patients were analyzed with magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and cholangiography using catheter via percutaneous or nasobiliary routes, selectively. Then, the types of patients confirmed to have aPHD were classified and analyzed for the presence of BDI. Results: Of the 1429 patients, 123 patients (8.61%) were found to have aPHD, of which 7 patients (0.49%) were type I, 14 patients (0.98%) were type II, 84 patients (6.97%) were type III, 2 patients (0.14%) were type IV, 7 patients (0.49%) were type IV, 9 patients (0.63%) were miscellaneous type, respectively (Fig. 3). BDI occurred in 3 patients out of 1429 patients (0.21%), and among 123 patients with aPHD, there was only a case of transected aPHD during dissection of posterior wall of gallbladder. Conclusions: It is useful to perform preoperative examination using MRCP, ERCP, cholangiography to reduce BDI through accurate understanding of the anatomy of the biliary tract before laparoscopic cholecystectomy.