Avoiding Pitfalls in Cholecystectomy

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Introduction

The performance of a laparoscopic cholecystectomy can be technically challenging. Success depends on multiple factors including: patient anatomy, patient co-morbidities, pathologic changes in the gallbladder and surrounding tissue, pre-operative interventions attempted, and the individual surgeon's ability. Anticipating the attendant challenges, even during routine cases, can help to avoid several known complications associated with this procedure.

Pitfalls to avoid

The ultimate cause of injury is misidentification of the visualized structures. Poor visualization can be due to:

Pre-operative Pitfalls

Pathologic changes

  1. Acute Cholecystitis
  2. Severe gallstone pancreatitis
  3. Chronic inflammation with dense scarring
  4. The presence of large stones within the junction of the neck of the gallbladder and the cystic duct (Hartmann's pouch)
  5. Choledocho-enteral fistula
  6. Gangrenous changes to the gallbladder wall with adhesion formation to surrounding structures

Patient co-morbidities

  1. Obesity
  2. Liver cirrhosis – anticipate difficult gallbladder retraction and exposure
  3. Diabetes – despite minimal symptoms the disease may be very severe
  4. Previous abdominal surgery, particularly gastric or hepatic surgical procedures
  5. Gallbladder carcinoma

Anatomy

  1. Scars from previous surgery – anticipate difficult access and possible need for adhesiolysis
  2. Low sub-costal margin – anticipate difficult fundus retraction

Imaging/Therapeutic interventions

  1. A contracted gallbladder on ultrasound – anticipate severe adhesions and/or distorted anatomy
  2. If a pre-op ERCP was performed – anticipate adhesions within the triangle of Calot, be mindful of the possible presence of ERCP pancreatitis

Intra-Operative Pitfalls

  • Surgeon skill
  • Anatomic variations

Difficulties in identification include anatomic pitfalls occurring from 10-24% of cases. Every surgeon should pay attention to differentiate distortion of anatomy from anatomic variation.

  1. Short cystic duct
  2. Narrow common bile duct (CBD) – risks associated with < 3 mm, in some series 100% of CBD injuries are in ducts < 9 mm in size
  3. Unusual position or loop of the cystic duct or the right branch of the hepatic artery
  4. Any plunging hepatic duct from the confluence, usually from the posterior right duct
  5. Accessory duct from the right in the bed of the gallbladder
  6. Cystic duct passing posteriorly to the CBD and descending on its left side
  7. Multiple hepatic artery variations (most commonly right hepatic artery branching off the superior mesenteric artery)

Types of Injuries

Injuries due to anatomic variation

  • Small accessory bile duct injury – Luschka's ducts (ducts directly from gallbladder fossa to gallbladder) – while dissection in too deep a plane in the liver bed
  • Injury of a segmental or sectorial hepatic duct in case of a plunging hepatic duct
  • Partial or complete occlusion, or complete transection of the CBD if the cystic duct enters on the left
  • Associated vascular injury

Injuries not related to anatomy

  • Cystic duct injured or not closed (dissection, cannula, position of clip or ligature: technical problem)
  • Injury of cystic duct with segmental or sectorial hepatic duct (if normal upper confluence)
  • Partial or complete occlusion, excision, or transection of the CBD due to exposure and dissection that extends too low or too deep on the left lateral aspect of the operative field
  • CBD stenosis or occlusion due to excessive superior and lateral retraction on the infundibulum
  • Injury to the right hepatic duct (or any small aberrant duct along Calot's triangle) due to excessive lateral retraction

Suspected mechanisms of CBD injury

In order of frequency:

  • Difficulties of identification
  • Dissection too deep in the liver bed (accessory duct)
  • Malposition of clip
  • Thermal injury
  • Traumatic catheter placement or misinterpretation of cholangiogram
  • Combined mechanism
  • Injury caused by clip
  • Blind clipping near hilum
  • Technical failure of the surgeon or of the instrumentation
  • The presence of a bile duct stone
  • Carcinoma
  • Other or unidentified

Prevention of Injury

Common bile duct

The SAGES Safe Cholecystectomy Program now recommends the following strategies for minimizing bile duct injuries (for more details, please refer to their website):

  1. Use the Critical View of Safety (CVS) method of identification of the cystic duct and cystic artery during laparoscopic cholecystectomy.
    1. The hepatocystic triangle is cleared of fat and fibrous tissue.
    2. The lower one-third of the gallbladder is separated from the liver to expose the cystic plate.
    3. Two and only two structures should be seen entering the gallbladder.  Use a Doublet view (anterior and posterior images)
  2. Perform an intra-operative time-out during laparoscopic cholecystectomy prior to clipping, cutting or transecting and ductal structures.
  3. Understand the potential for aberrant anatomy in all cases.
  4. Make liberal use of cholangiography or other methods to image the biliary tree intraoperatively.
  5. Recognize when dissection is approaching a zone of great danger and halt the dissection before entering the zone.  Finish the operation by a safe method other than cholecystectomy if conditions around the gallbladder are too dangerous.
  6. Get help from another surgeon when the dissection or conditions are difficulty.

The common denominator of the development of CBD injuries is the failure to identify the structures of the Triangle of Calot. More than 2/3 of injuries are due to an inadequate Calot's dissection with confusion of normal anatomy. Maneuvers to provide maximum security include:

  1. Knowledge of the main anatomic variations
  2. High position of the laparoscope or use of the 30 degree oblique technique
  3. Reduce redundancy in the infundibulum of the gallbladder to open the Triangle of Calot.
  4. Retract the infundibulum such that the cystic duct is perpendicular (or angulated) to the main bile duct through sufficient lateral traction on the infundibulum to avoid the risk of injury to the right hepatic duct
  5. Do this is a way that does not position the cystic duct parallel to the CBD in order to avoid CBD tenting and the consequent risk of CBD stenosis or occlusion
  6. Dissect the infundibulum by section of the anterior and posterior peritoneum allowing one to visualize the structures at the base of the gallbladder
  7. Routine cholangiography (or sonography by few experts) is controversial, but has been advocated by several investigators. Cholangiography should be done in all doubtful cases
  8. Fundus first dissection if the Triangle of Calot is not clearly seen
  9. Only use clips to close a cleanly dissected cystic duct. Use free ties or suture ligatures for other situations
  10. Conversion if these steps do not provide the surgeon with comfortable anatomic orientation

Other situations

  • Previous lower abdominal adhesions – Palmer's point (3 cm below the left costal margin at the mid-clavicular line) is safest point for 1st entry
  • Contracted gallbladder – must watch for hepatic duct injuries as the gallbladder may be closely associated with the hepatic duct in this situation
  • Gallbladder perforation – be very gentle with tissue handling, particularly in thin walled gallbladder in children
  • Gangrenous/Perforated gallbladder – Fundus-first (retrograde) dissection; drain placement
  • Liver bed bleeding – Pressure with gallbladder itself; coagulate with ball cautery; irrigate to identify specefic bleeding areas, Surgicell with pressure; under-run with suture using a blunt hepatic needle
  • Cholecysto-duodenal fistula – Divide by cutting on the gallbladder wall and suture the duodenum at this interface
  • Tense distended gallbladder with Mucocoele/Pyocoele – Aspirate first
  • Obliterated Triangle of Calot – Dissect fundus-first and if necessary do a subtotal cholecystectomy with removal of all stones and placement of a drain after closure of the stump. Alternatively, the stump could be left open for a controlled fistula.
  • Avoid post-op bleeding from the cystic artery – avoid cauterizing the distal aspect of the artery as this leads to sloughing and possible post-operative hemorrhage