Oomman A, Murugan K, Rajaram K, Rasheed A. Methods of Cystic Duct Identification and Their Documentation During Laparoscopic Cholecystectomy Oomman A, Murugan K, Rajaram K, Rasheed A. Gwent Institute of Minimal Access Surgery Newport, Wales, UK

Laparoscopic cholecystectomy Laparoscopic surgery is the gold standard treatment for symptomatic gallstone disease2. The incidence of bile duct injury is between 0.1%-0.3% (1 in 500) in open cholecystectomy and 0.15%- 0.7% (1 in 200) in laparoscopic cholecystectomy2,6.

Videoscopic surgery is a visual discipline and the intra-operative anatomy is deduced by visual clues from a displayed image on a TV monitor with loss of the third dimension and tactile sensations. Recognition of such limitation and adoption of techniques to prevent mis-identification injury

Bile duct injury - 1 Is defined as an ‘accidental injury of any part of the major extra-hepatic biliary tract, excluding biliary leakage from the cystic duct or the gallbladder bed with an intact extra-hepatic biliary system’1 Always Morbid Occasionally Fatal Often Results in Litigation Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation.

Risk factors for BDI Training and experience: the ‘learning curve’5 The lack of 3D visualisation causing spatial disorientation5 The wrong identification of the biliary anatomy Local Operative Risk Factors: Acute Cholecystitis Chronic Inflammation Aberrant Anatomy Lack of conversion to an open cholecystectomy Incidence of biliary injury when laparoscopic cholecystectomy is performed for acute cholecystitis is three times greater than that for elective laparoscopic cholecystectomy

Causes for Misidentification BDI “common bile duct/cystic duct” variant: The common bile duct is mistaken for the cystic duct and is clipped and divided.

Causes for Misidentification BDI during LC I . Poor Retraction Correct Retraction Incorrect Retraction

Causes for Misidentification BDI during LC II . Disease Process Shortened Cystic Pedicle Shrunken Gallbladder

Causes for Misidentification BDI during LC III . Aberrant Anatomy This leads to Injury to an Aberrant Right Hepatic Duct (Present in 2% of Cases) Low Insertion of Right Hepatic Duct Low Union of Hepatic Ducts Cystic Duct Insertion Into Right Hepatic Duct

Causes for Misidentification BDI during LC IV Causes for Misidentification BDI during LC IV . Excessive Traction + Misidentification “Excessive Traction on the Gallbladder Pulls the Hepatic Ducts Down Leading to High Transections of the Biliary Tree”

Methods to Ensure Correct Identification of the Cystic Duct Dissection / Demonstration of the Calot’s Triangle Display of Critical View of Safety Utilization of Infundibular - Cystic Technique Use of Intra-operative Cholangiography

Calot’s Triangle The region in the liver bed bounded by the cystic artery, cystic duct and common hepatic duct

Critical View of Safety Complete dissection (all fat and fibrous tissue of the triangle of Callot) and separation of the base of the gallbladder from the liver bed. The anatomic rationale for identification of the cystic duct results from the fact that there are only two structures entering the gallbladder (Cystic Duct and Artery)

Infundibular Cystic Technique The cystic duct is isolated by dissection on the front and the back of the triangle of Calot and once isolated it is traced on to the gallbladder. Conclusive identification, occurs as a result of seeing the characteristic ‘flare’, as the cystic duct widens to become the gallbladder infundibulum.

Problems with the infundibular cystic technique The cystic duct may be hidden in some patients having laparoscopic cholecystectomy, especially in the presence of inflammation. This may lead to the deceptive appearance of a false infundibulum that misleads the surgeon into identifying the common bile duct as the cystic duct

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Are There Any Standardised Guidance to Avoid BDI by Ductal Misidentification? Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)

SAGES Guidelines Intraoperative cholangiogram may reduce the rate or severity of injury and improve injury recognition5. Recommends that the “critical view” is seen prior to dividing any structures5. The “infundibular” technique (identification of cystic duct and gallbladder junction) should be used whenever critical view of safety is not possible to perform5.

SAGES Guidance: Intra-operative Cholangiogram (IOC) Based on the hypothesis that identifying the anatomy of the biliary tree during LC would decrease the risk of injury to CBD IOC itself has an “albeit minimal” risk of CBD injury Bile Duct Injuries Occurred Even When IOC was Performed

Our Study Aim: To audit the quality of operative documentation of the method of anatomical cystic duct identification during LC .

Method The documentation of the method/s used for cystic duct identification was examined in 310 consecutive non-converted LCs that were carried out at Aneurin Bevan Health Board (ABHB) hospitals between the months of August 2010 and January 2011. Non- protocolised operation notes were studied and stratified into different groups I. No documentation of the method used II. Calot’s triangle was dissected or demonstrated III. Infundibular or infundibulo-cystic technique used IV. Critical view of safety (CVS) demonstrated V. Intra-operative cholangiogram used VI. Other methods

Results -1 The critical view of safety was demonstrated in (4/310) 1.3% of the cases. Infundibular or infundibulo-cystic technique was used to define the cystic duct in (9/310) 3.4% of the notes. Calot’s triangle was mentioned in (255/310) 82.3% of the notes.

Results -2 On table cholangiography was performed in (85/310) 27.4% of cases. In (43/310) 13.9% of cases, the cystic artery and duct were mentioned without any reference to critical view of safety, infundibular / infundibulo-cystic technique or Calot’s triangle

Results -3

Discussion - 1 The majority of laparoscopic Surgeons Do Not document their description of Cystic Duct Identification in accordance with SAGES Guideline An Educational and a Training Need is Identified Systematisation of Cystic Duct Identification may reduce BDI and we urge specialist laparoscopic societies to invest time and effort into this This will standardise training and competency testing

Discussion – 2 Written operative documentation of the methods of cystic duct identification in the during LC is sub-optimal and we recommend the adjuvant use of video / and or photo image to complement the written operation notes.

References Bile Duct Injury during Laparoscopic Cholecystectomy : Risk Factors, Mechanisms, Type, Severity and Immediate Detection J. Bile duct injury in the era of laparoscopic cholecystectomy S. Connor1 and O. J. Garden British Journal of Surgery 2006; 93: 158–168 The “Hidden Cystic Duct” Syndrome and the Infundibular Technique of Laparoscopic Cholecystectomy—the Danger of the False Infundibulum. Journal of American College of Surgeons 2000; Vol. 191, No. 6, Prevention of common bile duct injury during laparoscopic cholecystectomy. Hepatobiliary Pancreat Diseases International，Vol 8，2009 Sages guidelines for the clinical applications of laparoscopic biliary tract surgery Practice/Clinical Guidelines published on: 01/2010 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy. Pankaj G Roy,1 Zahir F Soonawalla, and Hugh W Grant. The Official Journal of the International Hepato Pancreato Biliary Association. 2009 March; 11(2): 130–134

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