HOWIDOIT
Avoidance
of Bile Duct Injury During Laparoscopic Cholecystectomy John G. Hunter,
Common bile duct (CBD) injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy. This may be a function of inadequate instruction, inadequate caution, or inexperience, or may represent an inherent flaw in laparoscopic exposure. The aim of this study was to identify several steps in laparoscopie exposure of the gallbladder, cystic duct, and Calot’s triangle to minimize the risk of surgical disorientation and CBD injury. A review of the first 180 laparoseopic cholecystectomies from the author’s series was performed. Maneuvers that provided optimal exposure of the critical anatomy were culled from the video record. These maneuvers were ( 1) routine use of a 30” forward oblique viewing telescope, (2) firm cephalic traction on the fundus of the gallbladder to reduce redundancy in the infundihulum of the gallbladder and best expose the cystic duct, (3) lateral traction on the infundibulwn of the gallbladder to place the cystic duct perpendicular to the CBD, (4) dissection of the cystic duct at the infundihuhun of the gaflbladder, and (5) routine fluoroscopic cholangiography. If these steps do not provide the surgeon with comfortable anatomic orientation, the procedure should be converted to open cholecystectomy.
MD, salt LakeCity,
Utah
aparoscopic cholecystectomy, driven by patient deL mand for a low-impact alternative to traditional cholecystectomy, has swept through the country at breakneck speed. Although there have been words of caution and a plea that initial studies be completed before widescale, uncontrolled proliferation of this procedure occurs [Z], such advice appears to have fallen on deaf ears. Early in the laparoscopic cholecystectomy experience of many skilled surgeons, bile duct injuries occurred [2-8]. Despite the expertise that has been gained in performing this procedure, bile duct injuries continue to occur as more surgeons begin to perform this procedure. The aim of this report is to describe five maneuvers that should minimiz the risk of common bile duct (CBD) injury when performing laparoscopic cholecystectomy. MATERIAL AND METHODS The video recordings of 180 laparoscopic
cholecystec tomies performed at the University of Utah by a single surgeon (JGH) between February 5,1990, and February $1991 were reviewed. Intense scrutiny was paid to the nineteenth case where the CBD was misidentified as the cystic duct. The cholangiogram, performed through the CBD, revealed the error and allowed for immediate repair of the choledochotomy. The maneuvers that were not present during this case, but have since been adopted to consistently provide clear definition of cystic and CBD anatomy, were culled from the video record. Details of the technique of laparoscopic cholecystectomy have been previously published [ 93. Before December 10,1990, a Oa forward-viewing telescope (Karl Storz, Tuttlingen, Germany) was used. After this date, all cholecystectomies were performed with a 30” forward oblique telescope. RESULTS
From the University of Utah Medical Center, Department of Surgery, Salt Lake City, Utah. Requests for reprints should be addressed to John G. Hunter, MD, Depwtment of Surgery, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132. Manuscript submitted January 2, 1991, and accepted in revised form April 2,199l.
Review of the video record demonstrated five steps that minh&ed the risk of a CBD injury. Step 1: Choosing a telescope. The first 149 cases in this series were performed with a 0’ forward-viewing telescope. The CBD was rarely seen with this optic. After changing to a 30° telescope, the CBD was frequently seen without dissection of the region. In addition, rotating the telescope to obtain different angles on the surgical field offered the surgeon more information to guide the safe dissection of Calot’s triangle. Step 2: Exposure of the cystic duct. The first maneuver is to obtain maximal cephalic retraction on the gallbladder and liver with an atraumatic grasper placed on the fundus of the gallbladder. This grasper is generally introduced through the port in the anterior axillary line. Maximal retraction provides maximum reduction of any redundancy in the gallbladder infundibulum. An infundibulum with a large impacted stone is especially likely to
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 JULY 1991
71
HUNTER
Figure 1. An atraumatic grasper placed through the most lateral trocar is advanced cephalad until all redundancy is removed from the gallbladder Infundibulum, thereby straightening ths cystic duct.
Igun, 2. The plans of Caloh triangle is tilted toward the telescope with posterior and lateral traction developed by an atraw matic grasper introduced tfrou@ the midclavlcular put.
obscure the cystic duct origin. In extreme cases of elonga-
tion, the redundant infundibulum may lie anterior and left of the CBD, drawing the bile duct into the domain of pericholecystic inflammation. While omental or duodenal adhesions may initially limit cephalic retraction of the gallbladder fundus, it is usually possible to continuously elevate the liver and gallbladder as adhesions are taken down (Figure 1). Adequate cephalic retraction of the gallbladder and liver has been achieved when the gallbladder infundibulwn can be seen tapering into the region of the cystic duct. If a second grasper introduced through the midsubcostal port is required to provide this 72
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
exposure, that grasper will not be available to provide the lateral traction required in step 2. When exposure of the tapering infundibulum has been achieved, the peritoneum overlying the gallbladder infundibulum is stripped with a fine dissecting grasper to reveal the presumptive cystic duct origin. At this point, the prudent surgeon should consider converting to open cholecystectomy if adhesions, inflammation, or bleeding preclude clear visualization of the junction of the gallbladder and cystic duct. Step 3: Tilting Calotf triangle. Generally, Calot’s triangle lies in the plane of the 0” forward-viewing telescope and cannot be adequately visualized without tilting the plane. This is accomplished by the first assistant. With an atraumatic grasper entering through the mid clavicular port, he or she pulls the cystic duct/gallbladder junction laterally and posteriorly, tilting the plane of the triangle toward the telescope and allowing a near enface view of the structures in the region (Figure 2). If a 30° scope is used, lateral traction alone is sufficient to provide en face visualization of Calot’s triangle. This maneuver places the cystic duct at right angles to the CBD and helps avoid tenting of the CBD. American manuals of laparoscopic cholecystectomy technique often show the first assistant placing axial traction on the gallbladder (Figure 3). Inadvertent dissection to the left of the CBD will occasionally occur if the CBD is tented by axial rather than lateral traction. If such an error is not immediately recognized, dissection along the duct toward the gallbladder will result in common hepatic duct transection, as has occurred many times in the United States already. If lateral traction pulls the cystic duct down behind the duodenum, an attempt should be made to improve cephalic traction on the fundus (step 2), increase the angle of reverse Trendelenburg, or further decompress the stomach and duodenum with the orogastric tube. Use of a 30” forward oblique viewing telescope virtually eliminates the duodenum as an obstacle to cystic duct exposure. Step 4: Opening Calotf triangle. With continued lateral traction on the neck of the gallbladder, the surgeon delicately spreads a double-action grasper between the cystic artery and the cystic duct (Figure 4). Breaking through this space may be facilitated by the first assistant elevating the cystic duct anteriorly to expose the posterior aspect of Calot’s triangle. From this angle, the surgeon may directly see the tip of the dissector between the cystic duct and cystic artery. A hook or right-angle electrosurgical knife is then used to coagulate and divide several small vessels and lymphatics bridging the gap between the cystic duct and artery to further open Calot’s triangle. A 1Scm length of cystic duct is adequate for cholangiography and ligature. No attempt is made to dissect the cystic duct down to the common duct, as bleeding in this area cannot be safely controlled without risking coagulation injury to the CBD. When this dissection is complete, lateral traction on the infundibulum of the gallbladder should reveal the liver through the gap between the cystic artery and duct. 162
JULY
199 1
BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Calcap.,NomaHc,corn).
The cystic duct must be seen widening into the gallbladder infundibulum in all cases. Lf this transition is not adequately visualized, further dissection of fat and loose connective tissue must be performed in the angle between the gallbladder infundibulum and the cystic duct. When all members of the operating team are content that the dime&on is complete, a clip applier is placed around the cystic duct and slid up onto the infundibulum of the gallbladder where it is fved and held for performance of choiangiography (Figure 5).
Step 5: Operativecholangiography. Cholangiography is performed with a 4F or 5F whiitletipped ureteral catheter placed through a small anterior cystic ductotomy made immediately below the clip on the infundibulum of the gallbladder. The likelihood of successful performance of cystic duct cholangiography is high if one adopts the following principles: (2) The midclavicular trocar should be placed immediately below the costal margin (approximately ‘Afinger breadth) in order to best align the microscissors and cholangiogram catheter with
Flg~e5.Ahemoclipisplacedonthei-ofthegallbladderandtractianonthecyWductismeintainedwiththe closed clipper to facilitate cholanglogaphy.
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
162
JULY 1991
73
the cystic duct. (2) The cystic ductotomy is made with the microscissors entering through the midclavicular trocar. With a grasper or clip applier on the gallbladder infundibulum, the surgeon aligns the cystic duct parallel to the microscissors in the axial plane (as the telescope views the action) and then tilts the duct back towards the liver (if necessary) to provide an angle of 30’ to 60° in the sagittal plane. If the ductotomy is small, the tip of the scissors can be inserted into the cystic duct and the hole gently dilated. (3) The cholangiogram catheter follows the same path as the scissors into the cystic duct and the tip is gently coaxed through the valves of Heister. If a cholangioclamp (Karl Storz, Tuttlingen, Germany) is not available, the percutaneous puncture site for the catheter guide should be adjacent to the midclavicular port. If the cystic duct cannot be deeply cannulated because of spiral valves, the catheter can usually be trimmed back to the last side hole and secured a few millimeters into the cystic duct. The epigastric trocar is secured off the field, and a cholangiogram is performed. Digital fluoroscopic cholangiography with a portable C-arm and image management system (OEC Diasonics, Salt Lake City, Utah) was used for the majority of these patients. In the first 180 patients, cholangiograms were attempted in 177 and were successfully completed in 157 (89%). When we reviewed our first 100 cases, routine cholangiography helped prevent CBD stricture in 2 patients and prevented bile duct transection in a third [IO]. There were no patients with retained stones in this series. The potential CBD injuries that were recognized and appropriately managed were: (1) extrinsic compression of the CBD by a clip placed on the cystic artery prior to cholangiography, and (2) narrowing of the CBD by traction on a short, wide-mouthed cystic duct. A cholangiogram from this second patient (Figure 6) shows the
74
THE AMERICAN JOURNAL OF SURGERY
cholangiogram clamp narrowing the lumen of the CBD. When the cholangiogram catheter was removed, traction on the CBD was released, the junction of the cystic and CBDs was exposed, and a single clip was placed across the wide-mouthed cystic duct between the CBD and the cystic ductotomy. A closed suction drain was placed adjacent to the tenuous duct closure. This patient experienced a moderate amount of bile drainage on her first postoperative day, but had no further bile leakage and a normal HIDA scan on her fourth postoperative day. The third patient had chronic inflammation of the gallbladder infundibulum extending into the porta hepatis. Retraction of the gallbladder pulled the CBD into the field of dissec tion where it was mistaken for the cystic duct. A cholangiogram through the CBD immediately revealed the error. A laparotomy and primary repair of the choledochotomy was performed. COMMENTS Five steps have been described to help diminish the likelihood of CBD injury. Step 1 emphasizes the advantage of a 30’ forward oblique viewing telescope over the more conventional 0’ forward-viewing optic. When a O” telescope is used, the CBD is rarely seen unless it is tented. The CBD lies parallel to the telescope and is usually hidden behind the duodenal bulb. A 30° telescope allows the surgeon to come “over the top” of the duodenal bulb and look down on the structures in the porta hepatis (if they are not covered with fat). The view of the CBD obtained with a 30’ telescope is nearly the same as that obtained from a right subcostal incision. In addition, the ability to change perspective by rotating the 30’ optic allows better visualization of the critical anatomy than can be obtained with a O” optic or through a subcostal incision.
VOLUME 162 JULY 1991
BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Step 2 emphasizes the cephalic traction on the fundus of the gallbladder necessary to open the porta hepatis and reduce redundancy in the gallbladder infundibuhun. If the infundibulum is not stretched (and this is indeed difficult when a large stone is impacted), it is difficult to expose the junction of the cystic duct and gallbladder. It is during this step that the decision to convert to open cholecystectomy should be made. If the dissection is bloody, if a difficult teasing dissection results in gallbladder holes, or if the anatomy is unclear, the prudent surgeon will elect to convert to open cholecystectomy. This decision is the most critical and most diicult to teach students of laparoscopic cholecystectomy. Step 3 defines the anatomic relationship between the cystic duct and CBD. Bile duct injuries with laparoscopic cholecystectomy appear to be more common in the U.S. (0.5 to 2.7%) than in Europe (0.33%) [2-81. While the reason for this may be illusory, a possible explanation is that American teaching stresses cephalic (axial) traction on the infundibulum of the gallbladder, tenting the CBD and risking its misidentification. From the perspective of the telescope, the distal CBD appears continuous with the cystic duct and can easily be mistakenly identified as a long cystic duct. European instruction stresses the lateral retraction depicted in this study [I 1,I 21. Such retraction places the cystic duct at right angles to the CBD, reducing the likeliiood of misidentification. Step 4 is arguably the most important step in preventing CBD injury. No clip should be placed on, and no incision should be made in, any structure until the transition between cystic duct and gallbladder infundibulum is clearly visualized. It is not adequate to see the cystic duct “entering” the gallbladder as this may belie a tented CBD coursing behind the gallbladder, drawn up by chronic inflammation. That is, the cystic duct must be seen widening into the gallbladder before one can certify accurate anatomic identification. In the case of the absent, or short, wide-mouthed cystic duct identified during this step or in step 5, the surgeon must consider conversion to open cholecystectomy or develop the skills to laparoscopically suture the cystic duct stump without impinging on the lumen of the CBD. Step 5, operative cholangiography, is as valuable for the anatomic information it provides as for the detection of choledocholithiasis. Although there are no prospective randomized trials comparing bile duct injury rates after routine or selective cholangiography, there is some evidence that CBD injury rates are lower in patients who have cholangiography performed during open cholecystectomy [13-151. Cholangiograms performed routinely in our first 100 laparoscopic cholecystectomies prevented CBD transection in one patient and avoided potential bile duct strictures in two other patients. Cholangiography also identified low-inserting accessory right hepatic ducts in another 3% of patients [IO]. Many unreported series are rife with unexplained bile leaks, some of which may be explained by inadvertent and unrecognized injury to accessory hepatic ducts that may enter the gallbladder, cystic duct, or common hepatic duct [16]. In summary,
routine cholangiography altered our operative behavior in 9% of our first 100 cases and in only three patients was the altered procedure the result of filling defects in the CBD [IO]. Surgeons advocating selective use of laparoscopic cholangiography cite the low incidence of clinically significant unsuspected bile duct stones as a reason not to do cholangiography. Couched behind this argument may be the real reasons why routine cholangiography is not beiig performed: many surgeons perceive it as difficult, timeconsuming, and dangerous, and consider the initial films frequently inadequate. The difficulties encountered performing laparoscopic cholangiography can be overcome with proper trocar placement and practice. Fluoroscopic cholangiography adds only 5 to 10 minutes of additional procedure time. Cholangiography-related complications have been nil in our series and are reportably rare in larger series. Without compromising the ability to detect small filling defects (2 mm or greater), digital fluoroscopic cholangiography eliminates the problem of waiting for the cholangiogram to be developed, ensures filling of intrahepatic ducts and duodenum, and helps distinguish air bubbles from CBD stones. In addition, the x-ray tube may be positioned to avoid interference from laparoscop ic hardware. Real-time fluoroscopic cholangiography may also help prevent CBD injury by giving the surgeon immediate feedback on bile duct anatomy. In one report, bile duct injury most frequently occurred while the surgeon was awaiting the return of the static cholangiogram [ 171. Many radiologists and gastroenterologists who have been performing fluoroscopic cholangiography (i.e., percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography) for many years find it difficult to believe that surgeons still rely on static cholangiograms. With laparoscopic cholecystectomy, we should be striving to reduce the rate of CBD injuries to the 0.2% incidence achieved with open cholecystectomy [ I7 1. The lowest reported incidence of CBD injury during laparoscopic cholecystectomy is greater than 0.3% [S] . Unfortunately, most surgical groups cannot claim such good re sults. Although the rate of CBD injury at laparoscopic cholecystectomy may never reach that of open cholecystectomy, if surgeons follow the five steps described here and have a liberal policy for conversion to open cholecystectomy, an acceptably low rate of bile duct injury may be achieved. REFERENCES 1. Cuschieri A, Berci G, McSherry CK. Laparosccpic cholecystectomy. Am J Surg 1990, 159: 273. 2. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparosccpic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 3. Reddick BJ. Laparoscopic laser cholecystectomy: the first 50 cases. Lasers Surg Med 1990 (suppl 2): 21. 4. Schultz LS, Hickok DF, Graber JN, et al. Laparosccpic cholecystectomy: a clinical trial. Laser Surg Med 1990 (suppl 2): 25. 5. Peters JH, Ellison C, Innes JT, et al. Safety and eflicacy of laparoscopic cholecystectomy. Ann Surg 1991; 213: 3-12. 6. Salky BA, Bauer JJ, Kreel I, Gelemt IM, Gortine SR. Laparo-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 JULY 1991
75
HUNTER
scopic cholecystectomy: an initial report. Gastrointest Endosc 199 1; 31: l-8. 7. Berci G, Sackier JM. The Los Angeles experience with laparo scopic cholecystectomy. Am J Surg 1991; 161: 382-4. 8. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparcscopic cholecystectomy. Am J Surg 1991; 161: 385-7. 9. Olsen Do. Iaparoscopic cholecystectomy. Am J Surg 199 1; 16 1: 339-44.
10. Bruhn EW, Miller FJ, Hunter JG. Routine fluoroscopic cholangiography during laparoscopic cholecystectomy: an argument. Surg Endosc (in press). 11. Perissat J, Collet D, Vitale G, Belliard R, Sosso M. Laparoscopic cholecystectomy using intracorporeal lithotripsy. Am J Surg 1991; 161: 371-6.
76
THE AMERICAN
JOURNAL OF SURGERY
12. Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211: 60-2. 13. Collins PG, Gorey PG. Iatrogenic biliary stricture: presentation and management. Br J Surg 1984; 71: 980-I. 14. Scher KS, Scott-Conner CE. Complications of biliary surgery. Am Surg 1987; 53: 16-21. 15. Moosa AR, Mayer Ad, Stabile B. Iatrogenic injury to the bile duct. Arch Surg 1990; 125: 1028-31. 16. Merenstein D, MacGowan KM, Kune GA. Frequency of anatomical hazards during cholecystectomy. Dig Surg 1985; 2: 121-5. 17. Andren-Sandberg A, Alinder G, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy: pre- and perioperative factors of importance. Ann Surg 1985; 201: 328-32.
VOLUME 162 JULY 199 1
Avoidance
of Bile Duct Injury During Laparoscopic Cholecystectomy John G. Hunter,
Common bile duct (CBD) injury during laparoscopic cholecystectomy appears to have a higher incidence than during open cholecystectomy. This may be a function of inadequate instruction, inadequate caution, or inexperience, or may represent an inherent flaw in laparoscopic exposure. The aim of this study was to identify several steps in laparoscopie exposure of the gallbladder, cystic duct, and Calot’s triangle to minimize the risk of surgical disorientation and CBD injury. A review of the first 180 laparoseopic cholecystectomies from the author’s series was performed. Maneuvers that provided optimal exposure of the critical anatomy were culled from the video record. These maneuvers were ( 1) routine use of a 30” forward oblique viewing telescope, (2) firm cephalic traction on the fundus of the gallbladder to reduce redundancy in the infundihulum of the gallbladder and best expose the cystic duct, (3) lateral traction on the infundibulwn of the gallbladder to place the cystic duct perpendicular to the CBD, (4) dissection of the cystic duct at the infundihuhun of the gaflbladder, and (5) routine fluoroscopic cholangiography. If these steps do not provide the surgeon with comfortable anatomic orientation, the procedure should be converted to open cholecystectomy.
MD, salt LakeCity,
Utah
aparoscopic cholecystectomy, driven by patient deL mand for a low-impact alternative to traditional cholecystectomy, has swept through the country at breakneck speed. Although there have been words of caution and a plea that initial studies be completed before widescale, uncontrolled proliferation of this procedure occurs [Z], such advice appears to have fallen on deaf ears. Early in the laparoscopic cholecystectomy experience of many skilled surgeons, bile duct injuries occurred [2-8]. Despite the expertise that has been gained in performing this procedure, bile duct injuries continue to occur as more surgeons begin to perform this procedure. The aim of this report is to describe five maneuvers that should minimiz the risk of common bile duct (CBD) injury when performing laparoscopic cholecystectomy. MATERIAL AND METHODS The video recordings of 180 laparoscopic
cholecystec tomies performed at the University of Utah by a single surgeon (JGH) between February 5,1990, and February $1991 were reviewed. Intense scrutiny was paid to the nineteenth case where the CBD was misidentified as the cystic duct. The cholangiogram, performed through the CBD, revealed the error and allowed for immediate repair of the choledochotomy. The maneuvers that were not present during this case, but have since been adopted to consistently provide clear definition of cystic and CBD anatomy, were culled from the video record. Details of the technique of laparoscopic cholecystectomy have been previously published [ 93. Before December 10,1990, a Oa forward-viewing telescope (Karl Storz, Tuttlingen, Germany) was used. After this date, all cholecystectomies were performed with a 30” forward oblique telescope. RESULTS
From the University of Utah Medical Center, Department of Surgery, Salt Lake City, Utah. Requests for reprints should be addressed to John G. Hunter, MD, Depwtment of Surgery, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132. Manuscript submitted January 2, 1991, and accepted in revised form April 2,199l.
Review of the video record demonstrated five steps that minh&ed the risk of a CBD injury. Step 1: Choosing a telescope. The first 149 cases in this series were performed with a 0’ forward-viewing telescope. The CBD was rarely seen with this optic. After changing to a 30° telescope, the CBD was frequently seen without dissection of the region. In addition, rotating the telescope to obtain different angles on the surgical field offered the surgeon more information to guide the safe dissection of Calot’s triangle. Step 2: Exposure of the cystic duct. The first maneuver is to obtain maximal cephalic retraction on the gallbladder and liver with an atraumatic grasper placed on the fundus of the gallbladder. This grasper is generally introduced through the port in the anterior axillary line. Maximal retraction provides maximum reduction of any redundancy in the gallbladder infundibulum. An infundibulum with a large impacted stone is especially likely to
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 JULY 1991
71
HUNTER
Figure 1. An atraumatic grasper placed through the most lateral trocar is advanced cephalad until all redundancy is removed from the gallbladder Infundibulum, thereby straightening ths cystic duct.
Igun, 2. The plans of Caloh triangle is tilted toward the telescope with posterior and lateral traction developed by an atraw matic grasper introduced tfrou@ the midclavlcular put.
obscure the cystic duct origin. In extreme cases of elonga-
tion, the redundant infundibulum may lie anterior and left of the CBD, drawing the bile duct into the domain of pericholecystic inflammation. While omental or duodenal adhesions may initially limit cephalic retraction of the gallbladder fundus, it is usually possible to continuously elevate the liver and gallbladder as adhesions are taken down (Figure 1). Adequate cephalic retraction of the gallbladder and liver has been achieved when the gallbladder infundibulwn can be seen tapering into the region of the cystic duct. If a second grasper introduced through the midsubcostal port is required to provide this 72
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
exposure, that grasper will not be available to provide the lateral traction required in step 2. When exposure of the tapering infundibulum has been achieved, the peritoneum overlying the gallbladder infundibulum is stripped with a fine dissecting grasper to reveal the presumptive cystic duct origin. At this point, the prudent surgeon should consider converting to open cholecystectomy if adhesions, inflammation, or bleeding preclude clear visualization of the junction of the gallbladder and cystic duct. Step 3: Tilting Calotf triangle. Generally, Calot’s triangle lies in the plane of the 0” forward-viewing telescope and cannot be adequately visualized without tilting the plane. This is accomplished by the first assistant. With an atraumatic grasper entering through the mid clavicular port, he or she pulls the cystic duct/gallbladder junction laterally and posteriorly, tilting the plane of the triangle toward the telescope and allowing a near enface view of the structures in the region (Figure 2). If a 30° scope is used, lateral traction alone is sufficient to provide en face visualization of Calot’s triangle. This maneuver places the cystic duct at right angles to the CBD and helps avoid tenting of the CBD. American manuals of laparoscopic cholecystectomy technique often show the first assistant placing axial traction on the gallbladder (Figure 3). Inadvertent dissection to the left of the CBD will occasionally occur if the CBD is tented by axial rather than lateral traction. If such an error is not immediately recognized, dissection along the duct toward the gallbladder will result in common hepatic duct transection, as has occurred many times in the United States already. If lateral traction pulls the cystic duct down behind the duodenum, an attempt should be made to improve cephalic traction on the fundus (step 2), increase the angle of reverse Trendelenburg, or further decompress the stomach and duodenum with the orogastric tube. Use of a 30” forward oblique viewing telescope virtually eliminates the duodenum as an obstacle to cystic duct exposure. Step 4: Opening Calotf triangle. With continued lateral traction on the neck of the gallbladder, the surgeon delicately spreads a double-action grasper between the cystic artery and the cystic duct (Figure 4). Breaking through this space may be facilitated by the first assistant elevating the cystic duct anteriorly to expose the posterior aspect of Calot’s triangle. From this angle, the surgeon may directly see the tip of the dissector between the cystic duct and cystic artery. A hook or right-angle electrosurgical knife is then used to coagulate and divide several small vessels and lymphatics bridging the gap between the cystic duct and artery to further open Calot’s triangle. A 1Scm length of cystic duct is adequate for cholangiography and ligature. No attempt is made to dissect the cystic duct down to the common duct, as bleeding in this area cannot be safely controlled without risking coagulation injury to the CBD. When this dissection is complete, lateral traction on the infundibulum of the gallbladder should reveal the liver through the gap between the cystic artery and duct. 162
JULY
199 1
BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Calcap.,NomaHc,corn).
The cystic duct must be seen widening into the gallbladder infundibulum in all cases. Lf this transition is not adequately visualized, further dissection of fat and loose connective tissue must be performed in the angle between the gallbladder infundibulum and the cystic duct. When all members of the operating team are content that the dime&on is complete, a clip applier is placed around the cystic duct and slid up onto the infundibulum of the gallbladder where it is fved and held for performance of choiangiography (Figure 5).
Step 5: Operativecholangiography. Cholangiography is performed with a 4F or 5F whiitletipped ureteral catheter placed through a small anterior cystic ductotomy made immediately below the clip on the infundibulum of the gallbladder. The likelihood of successful performance of cystic duct cholangiography is high if one adopts the following principles: (2) The midclavicular trocar should be placed immediately below the costal margin (approximately ‘Afinger breadth) in order to best align the microscissors and cholangiogram catheter with
Flg~e5.Ahemoclipisplacedonthei-ofthegallbladderandtractianonthecyWductismeintainedwiththe closed clipper to facilitate cholanglogaphy.
THE AMERICAN
JOURNAL
OF SURGERY
VOLUME
162
JULY 1991
73
the cystic duct. (2) The cystic ductotomy is made with the microscissors entering through the midclavicular trocar. With a grasper or clip applier on the gallbladder infundibulum, the surgeon aligns the cystic duct parallel to the microscissors in the axial plane (as the telescope views the action) and then tilts the duct back towards the liver (if necessary) to provide an angle of 30’ to 60° in the sagittal plane. If the ductotomy is small, the tip of the scissors can be inserted into the cystic duct and the hole gently dilated. (3) The cholangiogram catheter follows the same path as the scissors into the cystic duct and the tip is gently coaxed through the valves of Heister. If a cholangioclamp (Karl Storz, Tuttlingen, Germany) is not available, the percutaneous puncture site for the catheter guide should be adjacent to the midclavicular port. If the cystic duct cannot be deeply cannulated because of spiral valves, the catheter can usually be trimmed back to the last side hole and secured a few millimeters into the cystic duct. The epigastric trocar is secured off the field, and a cholangiogram is performed. Digital fluoroscopic cholangiography with a portable C-arm and image management system (OEC Diasonics, Salt Lake City, Utah) was used for the majority of these patients. In the first 180 patients, cholangiograms were attempted in 177 and were successfully completed in 157 (89%). When we reviewed our first 100 cases, routine cholangiography helped prevent CBD stricture in 2 patients and prevented bile duct transection in a third [IO]. There were no patients with retained stones in this series. The potential CBD injuries that were recognized and appropriately managed were: (1) extrinsic compression of the CBD by a clip placed on the cystic artery prior to cholangiography, and (2) narrowing of the CBD by traction on a short, wide-mouthed cystic duct. A cholangiogram from this second patient (Figure 6) shows the
74
THE AMERICAN JOURNAL OF SURGERY
cholangiogram clamp narrowing the lumen of the CBD. When the cholangiogram catheter was removed, traction on the CBD was released, the junction of the cystic and CBDs was exposed, and a single clip was placed across the wide-mouthed cystic duct between the CBD and the cystic ductotomy. A closed suction drain was placed adjacent to the tenuous duct closure. This patient experienced a moderate amount of bile drainage on her first postoperative day, but had no further bile leakage and a normal HIDA scan on her fourth postoperative day. The third patient had chronic inflammation of the gallbladder infundibulum extending into the porta hepatis. Retraction of the gallbladder pulled the CBD into the field of dissec tion where it was mistaken for the cystic duct. A cholangiogram through the CBD immediately revealed the error. A laparotomy and primary repair of the choledochotomy was performed. COMMENTS Five steps have been described to help diminish the likelihood of CBD injury. Step 1 emphasizes the advantage of a 30’ forward oblique viewing telescope over the more conventional 0’ forward-viewing optic. When a O” telescope is used, the CBD is rarely seen unless it is tented. The CBD lies parallel to the telescope and is usually hidden behind the duodenal bulb. A 30° telescope allows the surgeon to come “over the top” of the duodenal bulb and look down on the structures in the porta hepatis (if they are not covered with fat). The view of the CBD obtained with a 30’ telescope is nearly the same as that obtained from a right subcostal incision. In addition, the ability to change perspective by rotating the 30’ optic allows better visualization of the critical anatomy than can be obtained with a O” optic or through a subcostal incision.
VOLUME 162 JULY 1991
BILE DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY
Step 2 emphasizes the cephalic traction on the fundus of the gallbladder necessary to open the porta hepatis and reduce redundancy in the gallbladder infundibuhun. If the infundibulum is not stretched (and this is indeed difficult when a large stone is impacted), it is difficult to expose the junction of the cystic duct and gallbladder. It is during this step that the decision to convert to open cholecystectomy should be made. If the dissection is bloody, if a difficult teasing dissection results in gallbladder holes, or if the anatomy is unclear, the prudent surgeon will elect to convert to open cholecystectomy. This decision is the most critical and most diicult to teach students of laparoscopic cholecystectomy. Step 3 defines the anatomic relationship between the cystic duct and CBD. Bile duct injuries with laparoscopic cholecystectomy appear to be more common in the U.S. (0.5 to 2.7%) than in Europe (0.33%) [2-81. While the reason for this may be illusory, a possible explanation is that American teaching stresses cephalic (axial) traction on the infundibulum of the gallbladder, tenting the CBD and risking its misidentification. From the perspective of the telescope, the distal CBD appears continuous with the cystic duct and can easily be mistakenly identified as a long cystic duct. European instruction stresses the lateral retraction depicted in this study [I 1,I 21. Such retraction places the cystic duct at right angles to the CBD, reducing the likeliiood of misidentification. Step 4 is arguably the most important step in preventing CBD injury. No clip should be placed on, and no incision should be made in, any structure until the transition between cystic duct and gallbladder infundibulum is clearly visualized. It is not adequate to see the cystic duct “entering” the gallbladder as this may belie a tented CBD coursing behind the gallbladder, drawn up by chronic inflammation. That is, the cystic duct must be seen widening into the gallbladder before one can certify accurate anatomic identification. In the case of the absent, or short, wide-mouthed cystic duct identified during this step or in step 5, the surgeon must consider conversion to open cholecystectomy or develop the skills to laparoscopically suture the cystic duct stump without impinging on the lumen of the CBD. Step 5, operative cholangiography, is as valuable for the anatomic information it provides as for the detection of choledocholithiasis. Although there are no prospective randomized trials comparing bile duct injury rates after routine or selective cholangiography, there is some evidence that CBD injury rates are lower in patients who have cholangiography performed during open cholecystectomy [13-151. Cholangiograms performed routinely in our first 100 laparoscopic cholecystectomies prevented CBD transection in one patient and avoided potential bile duct strictures in two other patients. Cholangiography also identified low-inserting accessory right hepatic ducts in another 3% of patients [IO]. Many unreported series are rife with unexplained bile leaks, some of which may be explained by inadvertent and unrecognized injury to accessory hepatic ducts that may enter the gallbladder, cystic duct, or common hepatic duct [16]. In summary,
routine cholangiography altered our operative behavior in 9% of our first 100 cases and in only three patients was the altered procedure the result of filling defects in the CBD [IO]. Surgeons advocating selective use of laparoscopic cholangiography cite the low incidence of clinically significant unsuspected bile duct stones as a reason not to do cholangiography. Couched behind this argument may be the real reasons why routine cholangiography is not beiig performed: many surgeons perceive it as difficult, timeconsuming, and dangerous, and consider the initial films frequently inadequate. The difficulties encountered performing laparoscopic cholangiography can be overcome with proper trocar placement and practice. Fluoroscopic cholangiography adds only 5 to 10 minutes of additional procedure time. Cholangiography-related complications have been nil in our series and are reportably rare in larger series. Without compromising the ability to detect small filling defects (2 mm or greater), digital fluoroscopic cholangiography eliminates the problem of waiting for the cholangiogram to be developed, ensures filling of intrahepatic ducts and duodenum, and helps distinguish air bubbles from CBD stones. In addition, the x-ray tube may be positioned to avoid interference from laparoscop ic hardware. Real-time fluoroscopic cholangiography may also help prevent CBD injury by giving the surgeon immediate feedback on bile duct anatomy. In one report, bile duct injury most frequently occurred while the surgeon was awaiting the return of the static cholangiogram [ 171. Many radiologists and gastroenterologists who have been performing fluoroscopic cholangiography (i.e., percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography) for many years find it difficult to believe that surgeons still rely on static cholangiograms. With laparoscopic cholecystectomy, we should be striving to reduce the rate of CBD injuries to the 0.2% incidence achieved with open cholecystectomy [ I7 1. The lowest reported incidence of CBD injury during laparoscopic cholecystectomy is greater than 0.3% [S] . Unfortunately, most surgical groups cannot claim such good re sults. Although the rate of CBD injury at laparoscopic cholecystectomy may never reach that of open cholecystectomy, if surgeons follow the five steps described here and have a liberal policy for conversion to open cholecystectomy, an acceptably low rate of bile duct injury may be achieved. REFERENCES 1. Cuschieri A, Berci G, McSherry CK. Laparosccpic cholecystectomy. Am J Surg 1990, 159: 273. 2. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparosccpic guided cholecystectomy. Am J Surg 1991; 161: 36-44. 3. Reddick BJ. Laparoscopic laser cholecystectomy: the first 50 cases. Lasers Surg Med 1990 (suppl 2): 21. 4. Schultz LS, Hickok DF, Graber JN, et al. Laparosccpic cholecystectomy: a clinical trial. Laser Surg Med 1990 (suppl 2): 25. 5. Peters JH, Ellison C, Innes JT, et al. Safety and eflicacy of laparoscopic cholecystectomy. Ann Surg 1991; 213: 3-12. 6. Salky BA, Bauer JJ, Kreel I, Gelemt IM, Gortine SR. Laparo-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 JULY 1991
75
HUNTER
scopic cholecystectomy: an initial report. Gastrointest Endosc 199 1; 31: l-8. 7. Berci G, Sackier JM. The Los Angeles experience with laparo scopic cholecystectomy. Am J Surg 1991; 161: 382-4. 8. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparcscopic cholecystectomy. Am J Surg 1991; 161: 385-7. 9. Olsen Do. Iaparoscopic cholecystectomy. Am J Surg 199 1; 16 1: 339-44.
10. Bruhn EW, Miller FJ, Hunter JG. Routine fluoroscopic cholangiography during laparoscopic cholecystectomy: an argument. Surg Endosc (in press). 11. Perissat J, Collet D, Vitale G, Belliard R, Sosso M. Laparoscopic cholecystectomy using intracorporeal lithotripsy. Am J Surg 1991; 161: 371-6.
76
THE AMERICAN
JOURNAL OF SURGERY
12. Dubois F, Icard P, Berthelot G, Levard H. Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 1990; 211: 60-2. 13. Collins PG, Gorey PG. Iatrogenic biliary stricture: presentation and management. Br J Surg 1984; 71: 980-I. 14. Scher KS, Scott-Conner CE. Complications of biliary surgery. Am Surg 1987; 53: 16-21. 15. Moosa AR, Mayer Ad, Stabile B. Iatrogenic injury to the bile duct. Arch Surg 1990; 125: 1028-31. 16. Merenstein D, MacGowan KM, Kune GA. Frequency of anatomical hazards during cholecystectomy. Dig Surg 1985; 2: 121-5. 17. Andren-Sandberg A, Alinder G, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy: pre- and perioperative factors of importance. Ann Surg 1985; 201: 328-32.
VOLUME 162 JULY 199 1
