1. 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

2. 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.

3. 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

4. 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.

5. 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

6. 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.

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

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

9. 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

10. 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”

11. 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

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

13. 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)

14. 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.

15. 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

16. 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)

17. 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.

18. 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

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

20. 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

21. 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.

22. 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

23. Results -3

24. 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

25. 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.

26. 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 March; 11(2): 130–134

27. THANK YOU