Skip to main content

SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A


Cholecystectomy is one of the most common general surgical operations performed worldwide. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality; it also increases the cost of treatment and can be a common reason for medico-legal suits against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for “Safe Laparoscopic Cholecystectomy” and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects, especially in small peripheral centers, was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have “Safe Cholecystectomy” guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group.

This is a preview of subscription content, access via your institution.



Acquired immune deficiency syndrome


Alkaline phosphatase


American Society of Anesthesiologists


Bile duct injury


Body mass index


Common bile duct


Contrast enhanced computerized tomography


Chronic hemolytic anemia


Common hepatic duct


Chronic obstructive pulmonary disease


Critical view of safety


Delayed laparoscopic cholecystectomy


European Association of Endoscopic Surgeons


External biliary fistula


Early laparoscopic cholecystectomy


Endoscopic retrograde cholangio-pancreatography


Endoscopic papillotomy and stone extraction


Fine needle aspiration cytology




Hepatobiliary iminodiacetic acid scan


Human immune deficiency virus


Intrahepatic biliary radical dilatation


Intraoperative cholangiogram


L’Institut de Recherchecontre les Cancers de l'AppareilDigestif


Kidney function test


Laparoscopic cholecystectomy


Laparoscopic common bile duct exploration


Liver function test


Low molecular weight heparin


Level of evidence


Magnetic resonance cholangiogram


Magnetic resonance cholangio-pancreatography


Mirizzi's syndrome


Open cholecystectomy


Oral hypoglycemic agents


Society of American Gastrointestinal and Endoscopic Surgeons


Society of Endoscopic and Laparoscopic Surgeons of India


Sickle cell disease


Total leucocyte count


White blood cell




  1. Shekelle PG, Woolf SH, Eccles M, Grimshaw J (1999) Developing clinical guidelines. West J Med 170:348–351

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW (1992) Laparoscopic cholecystectomy. The new “gold standard”? Arch Surg Chic Ill 1960 127:917-921-923

  3. Barkun JS, Barkun AN, Sampalis JS et al (1992) Randomised controlled trial of laparoscopic versus mini cholecystectomy. The McGill Gallstone Treatment Group. Lancet Lond Engl 340:1116–1119

    CAS  Article  Google Scholar 

  4. Berggren U, Gordh T, Grama D, Haglund U, Rastad J, Arvidsson D (1994) Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 81:1362–1365

    CAS  Article  Google Scholar 

  5. Okamoto K, Suzuki K, Takada T et al (2018) Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepato-Biliary-Pancreat Sci 25:55–72.

    Article  Google Scholar 

  6. Lyu Y, Cheng Y, Wang B, Zhao S, Chen L (2018) Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: an up-to-date meta-analysis of randomized controlled trials. Surg Endosc 32:4728–4741.

    Article  PubMed  Google Scholar 

  7. Wang A-J, Wang T-E, Lin C-C et al (2003) Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis. World J Gastroenterol 9:2821–2823

    Article  Google Scholar 

  8. Abbas SH, Ghazanfar MA, Gordon-Weeks AN, Reddy SR, Soonawalla Z, Silva MA (2018) Acalculous cholecystitis: is an elective interval cholecystectomy necessary. Dig Surg 35:171–176.

    Article  PubMed  Google Scholar 

  9. Chung YH, Choi ER, Kim KM, Kim MJ, Lee JK, Lee KT, Lee KH, Choo SW, Do YS, Choo IW (2012) Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis? J Clin Gastroenterol 46:216–219.

    Article  PubMed  Google Scholar 

  10. Gu MG, Kim TN, Song J, Nam YJ, Lee JY, Park JS (2014) Risk factors and therapeutic outcomes of acute acalculous cholecystitis. Digestion 90:75–80.

    Article  PubMed  Google Scholar 

  11. Soria Aledo V, Galindo Iñíguez L, Flores Funes D et al (2017) Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature. Rev Espanola Enfermedades Dig Organo Of Soc Espanola Patol Dig 109:708–718.

    Article  Google Scholar 

  12. Gurusamy KS, Davidson C, Gluud C, Davidson BR (2013) Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev CD005440.

  13. Yang D-J, Lu H-M, Guo Q et al (2018) Timing of laparoscopic cholecystectomy after mild biliary pancreatitis: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 28:379–388.

    Article  PubMed  Google Scholar 

  14. Uhl W, Müller CA, Krähenbühl L, Schmid SW, Schölzel S, Büchler MW (1999) Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease. Surg Endosc 13:1070–1076

    CAS  Article  Google Scholar 

  15. Dedemadi G, Nikolopoulos M, Kalaitzopoulos I, Sgourakis G (2016) Management of patients after recovering from acute severe biliary pancreatitis. World J Gastroenterol 22:7708–7717.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Marangoni G, Hakeem A, Toogood GJ, Lodge JP, Prasad KR (2012) Treatment and surveillance of polypoid lesions of the gallbladder in the United Kingdom. HPB 14:435–440.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bhatt NR, Gillis A, Smoothey CO et al (2016) Evidence based management of polyps of the gall bladder: a systematic review of the risk factors of malignancy. Surg J R Coll Surg Edinb Irel 14:278–286.

    Article  Google Scholar 

  18. Chou S-C, Chen S-C, Shyr Y-M, Wang S-E (2017) Polypoid lesions of the gallbladder: analysis of 1204 patients with long-term follow-up. Surg Endosc 31:2776–2782.

    Article  PubMed  Google Scholar 

  19. Elmasry M, Lindop D, Dunne DFJ et al (2016) The risk of malignancy in ultrasound detected gallbladder polyps: a systematic review. Int J Surg Lond Engl 33(Pt A):28–35.

    Article  Google Scholar 

  20. Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK (2014) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc 28:875–885.

    Article  PubMed  Google Scholar 

  21. Singh AN, Kilambi R (2018) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc 32:3763–3776.

    Article  PubMed  Google Scholar 

  22. Antoniou SA, Antoniou GA, Makridis C (2010) Laparoscopic treatment of Mirizzi syndrome: a systematic review. Surg Endosc 24:33–39.

    Article  PubMed  Google Scholar 

  23. Currò G, Iapichino G, Lorenzini C, Palmeri R, Cucinotta E (2006) Laparoscopic cholecystectomy in children with chronic hemolytic anemia. Is the outcome related to the timing of the procedure? Surg Endosc 20:252–255.

    Article  PubMed  Google Scholar 

  24. Khan ZS, Livingston EH (1960) Huerta S (2011) Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature. Arch Surg Chic Ill 146:1143–1147.

    Article  Google Scholar 

  25. Stephen AE, Berger DL (2001) Carcinoma in the porcelain gallbladder: a relationship revisited. Surgery 129:699–703.

    CAS  Article  PubMed  Google Scholar 

  26. Kilic A, Sheer A, Shah AS et al (2013) Outcomes of cholecystectomy in US heart transplant recipients. Ann Surg 258:312–317.

    Article  PubMed  Google Scholar 

  27. Kao LS, Flowers C, Flum DR (2005) Prophylactic cholecystectomy in transplant patients: a decision analysis. J Gastrointest Surg Off J Soc Surg Aliment Tract 9:965–972.

    Article  Google Scholar 

  28. Hill PA, Harris RD (2016) Clinical importance and natural history of biliary sludge in outpatients. J Ultrasound Med Off J Am Inst Ultrasound Med 35:605–610.

    Article  Google Scholar 

  29. Lee YS, Kang BK, Hwang IK, Kim J, Hwang JH (2015) Long-term outcomes of symptomatic gallbladder sludge. J Clin Gastroenterol 49:594–598.

    Article  PubMed  Google Scholar 

  30. Persson GE, Thulin AJ (1991) Prevalence of gallstone disease in patients with diabetes mellitus. A case-control study. Eur J Surg Acta Chir 157:579–582

    CAS  Google Scholar 

  31. Del Favero G, Caroli A, Meggiato T et al (1994) Natural history of gallstones in non-insulin-dependent diabetes mellitus. A prospective 5-year follow-up. Dig Dis Sci 39:1704–1707

    Article  Google Scholar 

  32. Sedaghat N, Cao AM, Eslick GD, Cox MR (2017) Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis. Surg Endosc 31:673–679.

    Article  PubMed  Google Scholar 

  33. Nasioudis D, Tsilimigras D, Economopoulos KP (2016) Laparoscopic cholecystectomy during pregnancy: a systematic review of 590 patients. Int J Surg Lond Engl 27:165–175.

    Article  Google Scholar 

  34. Muench J, Albrink M, Serafini F et al (2001) Delay in treatment of biliary disease during pregnancy increases morbidity and can be avoided with safe laparoscopic cholecystectomy. Am Surg 67(539):542–543

    Google Scholar 

  35. Rollins MD, Chan KJ, Price RR (2004) Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc 18:237–241.

    CAS  Article  PubMed  Google Scholar 

  36. Leandros E, Gomatos IP, Mami P et al (2005) Elective laparoscopic cholecystectomy for symptomatic gallstone disease in patients receiving anticoagulant therapy. J Laparoendosc Adv Surg Tech A 15:357–360.

    Article  PubMed  Google Scholar 

  37. Ercan M, Bostanci EB, Ozer I, Ulas M, Ozogul YB, Teke Z, Akoglu M (2010) Postoperative hemorrhagic complications after elective laparoscopic cholecystectomy in patients receiving long-term anticoagulant therapy. Langenbeck's Arch Surg 395:247–253.

    Article  Google Scholar 

  38. Leiva JI, Etter EL, Gathe J et al (1997) Surgical therapy for 101 patients with acquired immunodeficiency syndrome and symptomatic cholecystitis. Am J Surg 174:414–416

    CAS  Article  Google Scholar 

  39. Ricci M, Puente AO, Rothenberg RE et al (1999) Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: indications and results in fifty-three patients. Surgery 125:172–177

    CAS  Article  Google Scholar 

  40. Carroll BJ, Rosenthal RJ, Phillips EH, Bonet H (1995) Complications of laparoscopic cholecystectomy in HIV and AIDS patients. Surg Endosc 9:874–878

    CAS  Article  Google Scholar 

  41. Laurence JM, Tran PD, Richardson AJ, Pleass HC, Lam VW (2012) Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB 14:153–161.

    Article  PubMed  PubMed Central  Google Scholar 

  42. de Goede B, Klitsie PJ, Hagen SM et al (2013) Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Br J Surg 100:209–216.

    Article  PubMed  Google Scholar 

  43. Machado NO (2012) Laparoscopic cholecystectomy in cirrhotics. JSLS 16:392–400.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Lal P, Agarwal P, Malik VK, Chakravarti A (2002) A difficult laparoscopic cholecystectomy that requires conversion to open procedure can be predicted by preoperative ultrasonography. JSLS 6:59–63

    PubMed  PubMed Central  Google Scholar 

  45. Liang B, Dai M, Zou Z (2016) Safety and efficacy of antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy: a systematic review and meta-analysis. J Gastroenterol Hepatol 31:921–928.

    CAS  Article  PubMed  Google Scholar 

  46. Kramp KH, van Det MJ, Totte ER, Hoff C, Pierie JP (2014) Ergonomic assessment of the French and American position for laparoscopic cholecystectomy in the MIS Suite. Surg Endosc 28:1571–1578.

    Article  PubMed  Google Scholar 

  47. Ahmad G, Gent D, Henderson D et al (2015) Laparoscopic entry techniques. Cochrane Database Syst Rev.

  48. Vilos GA, Ternamian A, Dempster J, Laberge PY (2007) Clinical Practice Gynaecology Committee. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC 29(5):433–447

    Article  Google Scholar 

  49. Gurusamy KS, Vaughan J, Davidson BR (2014) Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev CD006930.

  50. Anatomy and Surgical Relevance of Rouviere’s Sulcus. Accessed 2 Jan 2019

  51. Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125

    CAS  PubMed  Google Scholar 

  52. Avgerinos C, Kelgiorgi D, Touloumis Z et al (2009) One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J Gastrointest Surg Off J Soc Surg Aliment Tract 13:498–503.

    CAS  Article  Google Scholar 

  53. Jiang H-P, Liu Y-D, Li Y-S et al (2017) Ultrasonic versus electrosurgical device for laparoscopic cholecystectomy: a systematic review with meta-analysis and trial sequential analysis. Int J Surg 40:24–32.

    Article  PubMed  Google Scholar 

  54. Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ (2019) Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc 33:724–730.

    Article  PubMed  Google Scholar 

  55. Vadlamudi R, Conway J, Mishra G et al (2014) Identifying patients most likely to have a common bile duct stone after a positive intraoperative cholangiogram. Gastroenterol Hepatol 10:240–244

    Google Scholar 

  56. Gurusamy KS, Koti R, Davidson BR (2013) Routine abdominal drainage versus no abdominal drainage for uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev CD006004.

  57. Nachnani J, Supe A (2005) Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters. Indian J Gastroenterol Off J Indian Soc Gastroenterol 24:16–18

    Google Scholar 

  58. Hussien M, Appadurai IR, Delicata RJ, Carey PD (2002) Laparoscopic cholecystectomy in the grossly obese: 4 years experience and review of literature. HPB 4:157–161.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  59. Akcakaya A, Okan I, Bas G, Sahin G, Sahin M (2015) Does the difficulty of laparoscopic cholecystectomy differ between genders? Indian J Surg 77:452–456.

    Article  PubMed  Google Scholar 

  60. Yol S, Kartal A, Vatansev C, Aksoy F, Toy H (2006) Sex as a factor in conversion from laparoscopic cholecystectomy to open surgery. JSLS 10:359–363

    PubMed  PubMed Central  Google Scholar 

  61. Kartal A, Aksoy F, Vatansev C et al (2001) Does estrogen cause low conversion rates in laparoscopic cholecystectomies for acute and chronic cholecystitis in women? JSLS 5:309–312

    CAS  PubMed  PubMed Central  Google Scholar 

  62. Yetkin G, Uludag M, Oba S, Citgez B, Paksoy I (2009) Laparoscopic cholecystectomy in elderly patients. JSLS 13:587–591.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Hayama S, Ohtaka K, Shoji Y et al (2016) Risk factors for difficult laparoscopic cholecystectomy in acute cholecystitis. JSLS 20.

  64. Pessaux P, Tuech J-J, Derouet N, Rouge C, Regenet N, Arnaud JP (2000) Laparoscopic cholecystectomy in the elderly. Surg Endosc 14:1067–1069.

    CAS  Article  PubMed  Google Scholar 

  65. Ammori BJ, Vezakis A, Davides D et al (2001) Laparoscopic cholecystectomy in morbidly obese patients. Surg Endosc 15:1336–1339.

    CAS  Article  PubMed  Google Scholar 

  66. da Costa DW, Schepers NJ, Bouwense SA et al (2018) Predicting a “difficult cholecystectomy” after mild gallstone pancreatitis. HPB.

  67. Sinha R (2008) Early laparoscopic cholecystectomy in acute biliary pancreatitis: the optimal choice? HPB 10:332–335.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Bat O (2015) The analysis of 146 patients with difficult laparoscopic cholecystectomy. Int J Clin Exp Med 8:16127–16131

    PubMed  PubMed Central  Google Scholar 

  69. Malik A, Laghari AA, Talpur KAH, Memon A, Mallah Q, Memon JM (2007) Laparoscopic cholecystectomy in empyema of gall bladder: an experience at Liaquat University Hospital, Jamshoro, Pakistan. J Minimal Access Surg 3:52–56.

    Article  Google Scholar 

  70. Machi J, Johnson JO, Deziel DJ, Soper NJ, Berber E, Siperstein A, Hata M, Patel A, Singh K, Arregui ME (2009) The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc 23:384–388.

    Article  PubMed  Google Scholar 

  71. Santos BF, Brunt LM, Pucci MJ (2017) The difficult gallbladder: a safe approach to a dangerous problem. J Laparoendosc Adv Surg Tech 27:571–578.

    Article  Google Scholar 

  72. Strasberg SM, Pucci MJ, Brunt LM, Deziel DJ (2016) Subtotal cholecystectomy-“fenestrating” vs “reconstituting” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 222:89–96.

    Article  PubMed  Google Scholar 

  73. Henneman D, da Costa DW, Vrouenraets BC, van Wagensveld B, Lagarde SM (2013) Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surg Endosc 27:351–358.

    Article  PubMed  Google Scholar 

  74. Elshaer M, Gravante G, Thomas K et al (2015) Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 150:159–168.

    Article  PubMed  Google Scholar 

  75. Kulen F, Tihan D, Duman U, Bayam E, Zaim G (2016) Laparoscopic partial cholecystectomy: a safe and effective alternative surgical technique in difficult cholecystectomies. Ulus Cerrahi Derg 32:185–190.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Kelly MD (2009) Laparoscopic retrograde (fundus first) cholecystectomy. BMC Surg 9:19.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Gupta A, Agarwal PN, Kant R, Malik V (2004) Evaluation of fundus-first laparoscopic cholecystectomy. JSLS 8:255–258

    PubMed  PubMed Central  Google Scholar 

  78. Mahmud S, Masaud M, Canna K, Nassar AHM (2002) Fundus-first laparoscopic cholecystectomy. Surg Endosc 16:581–584.

    CAS  Article  PubMed  Google Scholar 

  79. Strasberg SM, Gouma DJ (2012) “Extreme” vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB 14:1–8.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Ali A, Saeed S, Khawaja R et al (2016) Difficulties in laparoscopic cholecystectomy: conversion versus surgeon’s failure. J Ayub Med Coll Abbottabad JAMC 28:669–671

    PubMed  Google Scholar 

  81. Becker CD, Hassler H, Terrier F (1984) Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography. AJR Am J Roentgenol 143:591–596.

    CAS  Article  PubMed  Google Scholar 

  82. Choi BW, Kim MJ, Chung JJ, Chung JB, Yoo HS, Lee JT (2000) Radiologic findings of Mirizzi syndrome with emphasis on MRI. Yonsei Med J 41:144–146.

    CAS  Article  PubMed  Google Scholar 

  83. Yip AW, Chow WC, Chan J, Lam KH (1992) Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management. Surgery 111:335–338

    CAS  PubMed  Google Scholar 

  84. Kapoor VK (2010) Safe cholecystectomy A to Z. Lucknow: Shubham book distributors

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Virinder Kumar Bansal.

Ethics declarations

Conflict of interest

The authors declare that they do not have any conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


This consensus statement is for general guidance only; the recommendations made in this statement do not cover all situations and scenarios and may be modified depending upon the infrastructure and the expertise available in a given situation.


The term common bile duct (CBD) has been used in these guidelines. At most places, it means and includes common hepatic duct (CHD) also.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bansal, V.K., Misra, M., Agarwal, A.K. et al. SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A. Indian J Surg 83 (Suppl 3), 592–610 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Laparoscopic cholecystectomy
  • Bile duct injury
  • Guidelines for safe cholecystectomy
  • Prevention