Abstract
Introduction
Bile duct injuries have been substantially increased after the introduction of laparoscopic cholecystectomy (LC). They are accompanied by major morbidity, occasional mortality, lengthening of hospital stay, additional health costs, and deterioration of patients’ quality of life and life expectancy. The aim of this study was to present the method of “critical view of safety” (CVS) as safe and feasible for the prevention of bile duct injuries during laparoscopic cholecystectomy.
Patients and Methods
During a 6-year period from January 2002 till December 2007, 1,046 LCs (369 men and 677 women) were performed mainly for symptomatic gallstone disease. The CVS technique recommends clearing the triangle of Calot of fat and fibrous tissue and taking the gallbladder off the lowest part of its attachment to the gallbladder bed. The “infundibular” technique (identification of cystic duct and gallbladder junction) was used whenever CVS was not possible to perform.
Results
The CVS was performed in 998 patients (95.4%). Overall, 27 patients needed conversion to the open approach (2.6%). This rate was higher in patients with acute inflammation undergoing early operation (nine of 128, 7%) compared with patients operated later or electively (18 of 914, 1.9%). There was no bile duct injury in the 1,046 cholecystectomies. Postoperatively, five patients had bile leaks which were transient and stopped spontaneously after 2–14 days. Two reoperations were performed because of severe bleeding.
Conclusion
CVS clarifies the relations of the anatomic structures that should be divided, and therefore, it should be ideally and routinely applied in all LCs because of its highly protective role against bile duct injuries.
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References
Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention of laparoscopic bile duct injuries. Analysis of 252 cases from a human factor and cognitive psychology perspective. Ann Surg 2003;237(4):460–469. doi:10.1097/00000658-200304000-00004.
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–125.
Richardson MC, Bell G, Fullarton GM. 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 1996;83:1356–1360. doi:10.1002/bjs.1800831009.
Hugh TB. New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots. Surgery 2002;132(5):826–835. doi:10.1067/msy.2002.127681.
Savader SJ, Lillemoe KD, Prescott CA, Winick AB, Venbrux AC, Lund GB, Mitchell SE, Cameron JL, Osterman FA Jr. Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster. Ann Surg 1997;225:268–273. doi:10.1097/00000658-199703000-00005.
Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006;93(2):158–168. doi:10.1002/bjs.5266.
Shea JA, Healey MJ, Berlin JA, Clarke JR, Malet PF, Staroscik RN, Schwartz JR, Williams SV. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996;224(5):609–620. doi:10.1097/00000658-199611000-00005.
Gates JA, Tompkins RK, Zinner MJ, Busuttil RW, Kallman C, Roslyn JJ. Biliary complications of laparoscopic cholecystectomy. Am Surg 1993;59:243–247.
Asbun HJ, Rossi RI, Lowell JA, Munson JI. Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention and management. World J Surg 1993;17:547–552. doi:10.1007/BF01655122.
Boerma D, Rauws EA, Kenlemans YC, Bergman JJ, Obertop H, Huibregtse K, Gouma DJ. Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis. Ann Surg 2001;234:750–757. doi:10.1097/00000658-200112000-00006.
Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 2003;290:2168–2173. doi:10.1001/jama.290.16.2168.
Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9(5):543–547. doi:10.1007/s005340200071.
Strasberg SM, Eagon CJ, Drebin JA. The «hidden cystic duct» syndrome and the infundibular technique of laparoscopic cholecystectomy—the danger of the false infundibulum. J Am Coll Surg 2000;191(3):661–667. doi:10.1016/S1072-7515(00)00717-1.
Strasberg SM. Biliary injury in laparoscopic surgery: Part 2. Changing the culture of cholecystectomy. J Am Coll Surg 2005;201(4):604–611. doi:10.1016/j.jamcollsurg.2005.04.032.
Walsh RM, Henderson JM, Vogt DP, Mayes JT, Grundfest-Broniatowski S, Gagner M, Ponsky JL, Hermann RE. Trends in bile duct injuries from laparoscopic cholecystectomy. J Gastrointest Surg 1998;2(5):458–462. doi:10.1016/S1091-255X(98)80037-1.
Buell IF, Cronin DC, Funaki B, Koffron A, Yoshida A, Lo A, Leef J, Millis JM. Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy. Arch Surg 2002;137:703–710. doi:10.1001/archsurg.137.6.703.
Stewart L, Robinson TN, Lee CM, Liu K, Whang K, Way LW. Right hepatic artery injuryassociated with laparoscopic bile duct injury: incidence, mechanism and consequences. J Gastrointest Surg 2004;8:523–531. doi:10.1016/j.gassur.2004.02.010.
Flum DR, Koepsell T, Heagerty P, Sinanan M, Dellinger EP. Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography: adverse outcome or preventable error? Arch Surg 2001;136:1287–1292. doi:10.1001/archsurg.136.11.1287.
Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T. Intraoperative cholangiography and the risk of common bile duct injury during cholecystectomy. JAMA 2003;289:1639–1644. doi:10.1001/jama.289.13.1639.
Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population based study. Ann Surg 1999;229:449–457. doi:10.1097/00000658-199904000-00001.
Russell JC, Walsh SJ, Mattie AS, Lynch JT. Bile duct injuries 1989–1993. A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg 1996;131(4):382–388.
Gigot JF. Bile duct injury during laparoscopic cholecystectomy: risk factors, mechanisms, type, severity and immediate detection. Acta Chir Belg 2003;103(2):154–160.
Gadzijev EM. Surgical anatomy of hepatoduodenal ligamentand hepatic hilus. J Hepatobiliary Pancreat Surg 2002;9(5):531–533. doi:10.1007/s005340200068.
MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 1998;12(4):315–321. doi:10.1007/s004649900661.
Shamiyeh A, Wayant W. Laparoscopic cholecystectomy: early and late complications and their treatment. Langenbecks Arch Surg 2004;389(3):164–171. Jun laparoscopic cholecystectomy.
Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury dyring laparoscopic cholecystectomy: results of a national survey. Am Surg 2001;234:549–559.
Adams DB, Borowicz MR, Woolton FT III, Cunningham JT. Bile duct complications after laparoscopic cholecystectomy. Surg Endosc 1993;7:79–83. doi:10.1007/BF00704382.
Stewart L, Way LW. Bile duct complications during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;130:1123–1129.
Shah SR, Mirza DF, Afonso R, Mayer AD, McMaster P, Buckels JA. Changing referral pattern of biliary injuries sustained during laparoscopic cholecystectomy. Br J Surg 2000;87:890–891. doi:10.1046/j.1365-2168.2000.01446.x.
Schmidt SC, Langrehr JM, Hintze RE, Neuhaus P. Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy. Br J Surg 2005;92:76–82. doi:10.1002/bjs.4775.
Acknowledgment
The authors would like to thank Prof. Steven Strasberg for his constructive review and comments on this manuscript.
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Avgerinos, C., Kelgiorgi, D., Touloumis, Z. et al. One Thousand Laparoscopic Cholecystectomies in a Single Surgical Unit Using the “Critical View of Safety” Technique. J Gastrointest Surg 13, 498–503 (2009). https://doi.org/10.1007/s11605-008-0748-8
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DOI: https://doi.org/10.1007/s11605-008-0748-8