Julia F Kohn1, Alexander Trenk2, Brittany Lapin2, John G Linn2, Stephen Haggerty2, Woody Denham2, Ray Joehl2, Michael B Ujiki2. 1University of Illinois at Chicago Medical School, 2Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University HealthSystem
INTRODUCTION: This study sought to determine the prevalence of, and risk factors for, biliary injury (BDI) during laparoscopic cholecystectomy (LC) within one four-hospital healthcare system.
METHODS: 500 cases between 2009 and 2015 were randomly selected and retrospectively reviewed, and preoperative, intraoperative, and postoperative data were collected. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of severity, ICD code, or need for a second procedure. Biliary injuries were classified per Strasberg et al (1995). Logistic regression models were utilized to identify univariate predictors of biliary injuries.
RESULTS: 30.4% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts described the critical view in detail consistent with the definition by Strasberg and the SAGES Safe Cholecystectomy Program. Six patients (1.2%) had a biliary injury (BDI) either intra- or postoperatively; two of those six had multiple BDI.
CONCLUSIONS: The rate of BDI in this study, 1.2%, is higher than the 0.3% rate cited by SAGES. Nearly all of the patients with biliary injury in this study had Class A and Class D injuries, and all were repaired within the institution; these are less likely to be identified by larger BDI studies. Although only 6 patients had a biliary complication, this study did identify potential risk factors. The only positive predictor was acute cholecystitis on pathology findings; necrosis/gangrene per surgeon and pathology and acute cholecystitis per surgeon were significantly increased in BDI patients, and there was also a trend towards significance with acute surgery. This seems to contradict findings from the Cochrane review of early LC for acute cholecystitis, which found no increase in BDI for patients having acute surgery for acute cholecystitis; however, the review also found high levels of bias in the studies used.
There is no correlation of Critical View of Safety with prevention of biliary injury, although only 12.4% of charts could be verified as following the method correctly. The low rates of documented CVS in the overall study population indicate that this technique is still not widely implemented. Furthermore, the utility of the Critical View is to prevent injury due to misidentification of structures, and is probably less likely to prevent class A injuries. Better implementation of the Critical View of Safety, and increased caution in dissecting acutely inflamed tissues, may be in order to prevent even minor biliary injuries.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79699
Program Number: S009
Presentation Session: Biliary
Presentation Type: Podium