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

• Published in: Journal of hepato-biliary-pancreatic sciences 2019-04, Vol.26 (4), p.123-127
• Main Author: Strasberg, Steven M.
• Format: Article
• Language: English
• Subjects: Acute cholecystitis; Bile; Bile duct injury; Biliary colic; Biliary injury; Cholecystectomy; Critical view of safety; Identification; Inflection point; Laparoscopic cholecystectomy; Laparoscopy; Subtotal cholecystectomy; Subtotal fenestrating cholecystectomy; Subtotal reconstituting cholecystectomy
• ISSN: 1868-6974; 1868-6982
• DOI: 10.1002/jhbp.616

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. Highlight Strasberg describes the three conceptual goals of cholecystectomy: (1) obtaining secure anatomical identification of key structures, (2) making the decision not to perform total cholecystectomy when conditions are too dangerous to obtain secure identification – the “inflection point” and (3) finishing the operation safely when secure anatomical identification is not possible.