A three‐step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review. (7th April 2019)

• Record Type: Journal Article
• Authors: Strasberg, Steven M.
• Is Part Of: Journal of hepato-biliary-pancreatic sciences. Volume 26:Number 4(2019)
• Page Start: 123
• Page End: 127
• Publication Date: 2019-04-07
• Subjects: 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; Liver -- Diseases -- Periodicals; Biliary tract -- Diseases -- Periodicals; Pancreas -- Diseases -- Periodicals; 617.556
• DOI: 10.1002/jhbp.616
• Languages: English
• ISSNs: 1868-6974

Abstract

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. Abstract : 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.