‘Colleaguography’ in place of cholangiography, to prevent bile duct injury during laparoscopic cholecystectomy

Abstract

Bile duct injury (BDI) is not uncommon during laparoscopic cholecystectomy (LC). Intra-operative cholangiography (IOC) has been recommended to reduce the risk of BDI during LC. Facilities for IOC are, however, scarcely available in India. The author suggests ‘in vicinity colleaguography’ (IVC) – opinion of a surgical colleague in vicinity – as an easy alternative to IOC.

Gallstone disease (GSD) is common all over the world. Cholecystectomy is the treatment for symptomatic GSD. Bile duct injury (BDI) is not uncommon complication of cholecystectomy. Most cholecystectomies today are performed laparoscopically. Laparoscopic cholecystectomy (LC) is associated with higher (about 2–3 times) risk of BDI than open cholecystectomy. BDI results in morbidity (even mortality) and offsets the advantages of LC; it also increases the cost and is a frequent cause for litigation.

Most BDIs during LC are caused by a visual perception error, i.e., misinterpretation of the biliary ductal anatomy in the form of an undilated normal-sized common bile duct (CBD) being mistaken for the cystic duct – it (CBD) is then dissected, clipped and divided; the common hepatic duct is then encountered which is also clipped and divided, thus resulting in excision of a segment of the CBD – the classical LC BDI. Abnormal (anomalous) biliary ductal anatomy, i.e., aberrant ducts in the Calot's triangle, and difficult gallbladder pathology, i.e., inflammation and fibrosis in the Calot's triangle, are also responsible for the causation of BDI. Many BDIs can be prevented if the biliary ductal anatomy is mapped by cholangiography – this can be pre-operative or intra-operative. Cholangiography to delineate biliary ductal anatomy, however, has to be routine, i.e., performed in every case, cf. cholangiography to detect CBD stones where it can be selective, i.e., performed in only moderate- or high-risk cases.

Some surgeons obtain a pre-operative magnetic resonance cholangiogram (MRC) in all patients undergoing LC;[1] while pre-operative MRC will demonstrate any anomalous (aberrant) bile ducts in the Calot's triangle, it does not still take care of the visual perception error (vide supra). Moreover, routine MRC before every LC is not a cost-effective or practical option.

Intra-operative cholangiography (IOC) (also called per-operative cholangiography [POC]) is helpful as it identifies the CBD and may, therefore, prevent BDI. However, the method to obtain a POC, i.e., making a nick in the cystic duct and introducing a fine catheter to inject contrast, may itself cause the BDI if the CBD is being misidentified as the cystic duct – the visual perception error (vide supra). Even if the cystic duct is correctly identified, the incision in the cystic duct may inadvertently extend into the CBD while the catheter is being introduced, thus resulting in a BDI. In addition to the logistics of obtaining a good cholangiogram in the operation room, IOC involves training, time and cost. Most reviews have shown that IOC may or may not decrease the risk of BDI; it not only helps in intra-operative detection of the BDI but also reduces the extent/severity of the BDI by preventing further injury. Intra-operative ultrasono cholangiography (IOUC) using laparoscopic ultrasonography (LUS)[2] and intra-operative fluorescent cholangiography (IFC) using indocyanine green[3] are other useful techniques to delineate the biliary ductal anatomy which may help reduce the incidence of BDI during LC.

SAGES Safe Cholecystectomy Program[4] suggests six strategies which a surgeon can employ to adopt a universal culture of safety for cholecystectomy and to minimise the risk of BDI. SAGES Strategy 4 mentions ‘make liberal use of cholangiography or other methods (i.e. IOUC, IFC) to image the biliary tree intra-operatively’. Circumstances, however, may vary according to populations and geographical locations.[5] Facilities, equipment, expertise and logistics for routine performance of IOC/LUS-IOUC/IFC are not available in most hospitals, including those attached to premier teaching institutions, in India.

SAGES Strategy 2 mentions ‘an intra-operative time-out which consists of a stop point in the operation to confirm that the critical view of safety has been achieved utilizing the doublet view prior to clipping, cutting or transecting any ductal structures’ – This is, however, done by the members of the operating team itself who have been involved in the operation and may still suffer from the heuristic error – unconscious but firmly held assumption of human visual perception.[6]

SAGES Strategy 6 mentions ‘when it is practical to obtain, the advice of a second surgeon is often very helpful under conditions in which the dissection is stalled, the anatomy is unclear or under other conditions deemed “difficult” by the surgeon’. Hori[7] also advises taking the opinion of an independent second observer who is unbiased from the heuristic impression of the operating surgeon.

The author suggests/recommends that the surgeon who is performing LC should always (i.e. in every cholecystectomy) call another colleague, who is available in the vicinity of the operation room to have a look at the biliary ductal anatomy before any structure is clipped or divided – in vicinity colleaguography (IVC). This colleague, though preferably one with more experience than the surgeon, could be anyone, even with less experience – what is required is a fresh and unbiased input to confirm the biliary ductal anatomy to avoid the visual perception error (vide supra). Sawyer[8] reported that telementoring using real-time audio and video telecommunication to the operating room is a safe and effective method for teaching the techniques of LC. IVC can also be obtained using a smartphone and one of the easily and freely available video sharing platforms, e.g., Facebook Live, Facetime and WhatsApp.

IVC is almost universally available, easy to obtain (requires just a phone call) and costs nothing (except a little bit of ego!). For a country like India, IVC is a good alternative to IOC and may prevent BDI during LC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.