A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review

Steven M. Strasberg

Research output: Contribution to journalReview articlepeer-review

30 Scopus citations

Abstract

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification – the “inflection point”; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy – and instead to “bail-out”. This “inflection point” is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.

Original languageEnglish
Pages (from-to)123-127
Number of pages5
JournalJournal of Hepato-Biliary-Pancreatic Sciences
Volume26
Issue number4
DOIs
StatePublished - Apr 2019

Keywords

  • Acute cholecystitis
  • Bile duct injury
  • Biliary colic
  • Biliary injury
  • Cholecystectomy
  • Critical view of safety
  • Inflection point
  • Laparoscopic cholecystectomy
  • Subtotal cholecystectomy
  • Subtotal fenestrating cholecystectomy
  • Subtotal reconstituting cholecystectomy

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