Complications in Biliary Surgery: Tips and Tricks

  • José M. SchiappaEmail author


Despite all “calls for attention” and many papers published alerting to the importance and high rates of iatrogenic lesions of the biliary tract, these lesions continue to happen, with unreasonable frequency.

This chapter approaches the incidences reported and the possible causes for it and presents “tips” on how to have it minimised. These “tips” go to present some technical details that may be of importance for all those who perform, regularly this kind of surgery. As the other chapters, some video clips showing examples of the problems are attached.


Portal Hypertension Biliary Tract Cystic Duct Acute Cholecystitis Bile Duct Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

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Video 2.1 Demonstration of the movement done with the “flag” manoeuvre and the way it allows to obtain the Critical View of Safety (MP4 11419 kb)
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Video 2.2 “Classical” iatrogenic lesion of the CBD. Improper view, without having obtained CVS. The cystic duct is short and narrow and too much traction gives raise to “camel hump” of the CBD (at 01:58). Intraoperative cholangiography does not help avoiding the lesion; it only shows that it has been produced (MP4 59698 kb)
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Video 2.3 An “almost” correct view of CVS has been obtained but it is not enough; it lacks freeing of the lower third of the gallbladder from its bed. There is a “camel hump” and the surgeon cuts a tubular structure without proper identification or control. The hepatic artery is well visualised, pulsating. Cystic duct arises from the right hepatic duct (MP4 62096 kb)
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Video 2.4 Many wrong technical steps in this cholecystectomy: gallbladder wrongly grasped and wrongly positioned. Lack of vision at the infundibulum. Aggressive and not appropriate forceps. Cutting structures without proper dissection, without proper identification and following cutting with aggressive cautery (MP4 39121 kb)
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Video 2.5 The use of electrosurgery, specially using the hook, can be extremely dangerous as, sometimes, there is a lack of control of the instrument. In this video, the hook, while dissecting the hilum of the gallbladder, “jumps” without being controlled, to the anterior surface of the duodenum. It was still active and burned the duodenum. The surgeon saw it but thought it would be a minimal problem. First day post-op, there was a duodenal perforation (MP4 7012 kb)
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Video 2.6 Acute situations can be complex and inflammation makes strong alterations in local anatomy. Acute cholecystitis can be accompanied by local abscesses (MP4 13069 kb)


  1. 1.
    Morgenstern L, Berci G (1992) Twelve hundred open cholecystectomies before the laparoscopic era a standard for comparison leon. Arch Surg 127(4):400–403Google Scholar
  2. 2.
    Castelo B et al (1998) Portug Soc Surg. Personal communication.Google Scholar
  3. 3.
    Chapman WC et al (1995) Postcholecystectomy bile duct strictures. Management and outcome in 130 patients. Arch Surg 130(6):597–602; discussion 602–604Google Scholar
  4. 4.
    Maetani Y, Itoh K et al (1998) Portal vein anomaly associated with deviation of the ligamentum teres to the right and malposition of the gallbladder. Radiology 207(3):723–728Google Scholar
  5. 5.
    Voitk AJ, Tsao SG et al (2001) The tail of the learning curve for laparoscopic cholecystectomy. Am J Surg 182(3):250–253Google Scholar
  6. 6.
    Morgenstern L. McGrath MF et al (1995) Continuing hazards of the learning curve in laparoscopic cholecystectomy. Am Surg 61(10):914–918Google Scholar
  7. 7.
    Calvete J, Sabater L et al (2000) Bile duct injury during laparoscopic cholecystectomy: myth or reality of the learning curve? Surg Endosc 14(7):608–611Google Scholar
  8. 8.
    Way LW et al (2003) Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237(4):460–469Google Scholar
  9. 9.
    Fullum TM et al (2013) Is Laparoscopy a Risk Factor for Bile Duct Injury During Cholecystectomy?. JSLS 17(3):365–370Google Scholar
  10. 10.
    Buddingh KT et al (2012) Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 26(1):79–85Google Scholar
  11. 11.
    McPartland KJ, Pomposelli JJ (2008) Iatrogenic biliary injuries: classification, identification, and management. Surg Clin North Am 88(6):1329–1343; ix. doi: 10.1016/j.suc.2008.07.006 Google Scholar
  12. 12.
    Nuzzo G (2009) Treatment of biliary lesions due to cholecystectomy. Chir Ital 61(5–6):519–521Google Scholar
  13. 13.
    Slim K, Martin G (2013) Does routine intra-operative cholangiography reduce the risk of biliary injury during laparoscopic cholecystectomy? An evidence-based approach. J Visc Surg 150(5):321–324Google Scholar
  14. 14.
    Hunter JG (1991) Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg 162(1):71–76Google Scholar
  15. 15.
    Strasberg SM, Hertl M et al (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180(1):101–125Google Scholar
  16. 16.
    Buddingh TK et al (2011) Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 25:2449–2461Google Scholar
  17. 17.
    Rawlings A et al (2010) Single-Incision Laparoscopic Cholecystectomy: Initial Experience with Critical View of Safety Dissection and Routine Intraoperative Cholangiography. J Am Coll Surg 211(1):1–7Google Scholar
  18. 18.
    Strasberg SM (2013) A teaching program for the “culture of safety in cholecystectomy” and avoidance of bile duct injury. J Am Coll Surg 217(4):751Google Scholar
  19. 19.
    Davidoff AM, Pappas TN et al (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215(3):196–202Google Scholar
  20. 20.
    Davidoff AM, Branum GD et al (1993) Clinical features and mechanisms of major laparoscopic biliary injury. Semin Ultrasound CT MR 14(5):338–345Google Scholar
  21. 21.
    Richardson MC, Bell G et al (1996) Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 83(10):1356–1360Google Scholar
  22. 22.
    McMahon AJ, Baxter JN et al (1993) Preventing complications of laparoscopy. Br J Surg 80(12):1593–1594Google Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of SurgeryHospital CUF Infante SantoLisbonPortugal

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