The importance of cognitive map placement in bile duct injuries

Anatomical Schemata Revealed by the Critical View of Safety Approach: A Proposal of the Hellenic Task Force on the Typology of Safe Laparoscopic Cholecystectomy (HETALCHO)

Background and objectives: Laparoscopic cholecystectomy (LC) is the most commonly performed operation in general surgery in the Western World. Gallbladder surgery, although most of the time simple, always offers the possibility of unpleasant surprises. Despite progress, the incidence of common bile duct injury is 0.2-0.4%, causing devastating implications for the patient and the surgeon. This is mainly due to the failure to identify the normal anatomy properly. The literature review reveals a lack of structured knowledge in the surgical anatomy of cholecystectomy. The aim of this study was to develop a framework with a common anatomical language for safe laparoscopic and open cholecystectomy. Materials and Methods: The Hellenic Task Force group on the typology for Safe Laparoscopic Cholecystectomy performed a critical review of the literature on the laparoscopic anatomy of cholecystectomy. The results were compared with those of a clinical study of 279 patients undergoing LC for uncomplicated symptomatic gallstone disease. Results: Fourteen elements encountered during LC under the critical view of safety (CVS) approach were determined. The typical vascular-biliary pedicle with one cystic duct distributed laterally (or caudally) and one cystic artery medially (or cranially) lying at any point of the hepatocystic space was found in 66% of the cases studied. Anatomical schemata were formulated corresponding to the norm and four variations. Conclusions: The proposed cognitive anatomical schemata summarize simply what one can expect in terms of deviation from the norm. We believe that the synergy between the correct application of the CVS and the structured knowledge of the surgical anatomy in cholecystectomy helps the surgeon to handle non-typical structures safely and to complete the laparoscopic or open cholecystectomy without vascular-biliary injuries.

Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

The evaluation of B-SAFE and ultrasonographic landmarks in safe orientation during laparoscopic cholecystectomy

INTRODUCTION

Even though the prevalence of bile duct injury (BDI) is nowadays lower than before and close to the era of open cholecystectomy, there is a strong need to make it even lower. B-SAFE is a group of five visual landmarks that may be used before dissection in the hepatocystic triangle for better orientation around the gallbladder. Another method is laparoscopic ultrasound (LUS), which enables confirmation of structures in the hepatoduodenal ligament and delineation of the safe plane of dissection.

AIM

To evaluate the use of B-SAFE and ultrasonographic landmarks during laparoscopic cholecystectomy in navigation around the gallbladder.

MATERIAL AND METHODS

The study group consisted of 158 patients with symptomatic cholecystolithiasis. The methods of intraoperative orientation around the gallbladder attempted in every patient during laparoscopic cholecystectomy included B-SAFE and ultrasonographic landmarks.

RESULTS

The identification rate of ultrasonographic landmarks - the upper border of "Mickey Mouse" sign (MMS) (the equivalent of the Rouviere's sulcus), the bile duct, and the hepatic artery - was significantly higher in patients with body mass index ≥ 30 kg/m2 and fibrosis and chronic inflammation in the gallbladder neck than B-SAFE. LUS was also significantly more successful in the identification of the bile duct in the whole study group than B-SAFE. There were no significant differences according to the identification of the duodenum. The conversion rate was 2.6%, and we did not observe any BDI.

CONCLUSIONS

Visual landmarks defined in B-SAFE are not as reliable as ultrasonographic landmarks; thus, LUS should be taken into consideration in the first place as a method of navigation around the gallbladder.

The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries

Laparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

The sulcus of the caudate process (Rouviere's sulcus): anatomy and clinical applications-a review of current literature

The sulcus of the caudate process is a horizontal groove on the inferior face of the liver. Its prevalence has not previously been determined. Because of its location, it represents a helpful extra-biliary landmark that could be used in biliary surgery to decrease bile duct injury. The goal of this study is to determine the prevalence of Rouviere's sulcus and describe its anatomy and relevant surgical applications. We conducted a literature review on the various characteristics of the sulcus, selecting anatomical clinical studies and dissections. We performed 10 cadaveric dissections in the Laboratory of Anatomy at Purpan University to determine the contents. We selected 12 anatomical studies, conducted between 1924 and January 1st, 2020, which included 2394 patients. The prevalence of the sulcus is 78.24% ± 9.1. Classification of Singh was used to describe anatomical characteristics. Type I ("deep sulcus") was identified in 50.4% ± 9.8 of cases, mostly consisting of Type Ia (open). Type II ("slit-like") was estimated to account for 13.3% ± 13.2, whereas Type III ("scar") described 12.3% ± 8.0. Average dimensions were estimated for length (26 mm ± 5.7), width (6.5 mm ± 1.5), and depth (7.9 mm ± 1.75). The content of the sulcus consists of the right portal vein and its division, the right hepatic artery, along with the right hepatic bile duct. The sulcus determines the orientation of the common bile duct. The sulcus of the caudate process is a reliable extra-biliary landmark, which presents a useful tool for reducing bile duct injuries during hepatobiliary surgery.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose

Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.

Methods

A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.

Results

All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury.

Conclusion

The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Iatrogenic bile duct injury: impact and management challenges

Iatrogenic bile duct injuries (BDIs) after laparoscopic cholecystectomy, being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery with a significant impact on patient's quality of life. The primary aim of this review was to discuss the classification of BDIs, the proposed methods to prevent biliary lesions, the associated risk factors, and the management challenges depending on the timing of recognition of the injury, its extension, the patient's clinical condition, and the availability of experienced hepatobiliary surgeons. Early recognition of BDI is of paramount importance and limiting the diagnosis delay is crucial for an optimal postoperative outcome. The therapeutic management depends on the type and gravity of the biliary lesion, and includes endoscopic, radiologic, and surgical approaches.