Surg Radiol Anat DOI 10.1007/s00276-015-1502-z
ANATOMIC BASES OF MEDICAL, RADIOLOGICAL AND SURGICAL TECHNIQUES
Visualizing biliary tracts with isosulphan blue to prevent injury during laparoscopic cholecystectomy: a preliminary cadaveric study Orhan Veli Ozkan1 • Orhan Yagmurkaya2 • Muhammed Feyzi Sahin3 Ahmet Selcuk Gurler3 • Hudaverdi Kucuker4
•
Received: 13 February 2015 / Accepted: 29 May 2015 Ó Springer-Verlag France 2015
Abstract Background Bile duct injury (BDI) as a complication of laparoscopic cholecystectomy may result in biliary cirrhosis with a high morbidity–mortality rate. Recurrent invasive procedures may be required for the optimum management. The most frequent causative factor in BDI is anatomical misidentification, particularly by inexperienced surgeons. Direct coloration of the cystic duct, bile duct, and gallbladder may decrease biliary tract injury. Methods This study was conducted during 10 standard, fresh cadaver autopsies at the Council of Forensic Medicine, Istanbul. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. Results Of the ten fresh cadavers, three were males and seven were females; the mean age at death was 43 years (range 22–76 years). Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct, was achieved in all of the cadavers. Conclusions Visualization of the biliary tract may reduce the risk associated with dissection of Calot’s triangle.
& Orhan Veli Ozkan [email protected] 1
Department of General Surgery, Faculty of Medicine, Sakarya University, Adnan Menderes Caddesi, Saglik Sokak No:193, 54100 Sakarya, Turkey
2
Department of General Surgery, Research and Educational Hospital, Sakarya University, 54100 Sakarya, Turkey
3
Council of Forensic Medicine, Bahc¸elievler, 34196 Istanbul, Turkey
4
Department of Forensic Medicine, Faculty of Medicine, Dumlupınar University, 43266 Sakarya, Turkey
Surgical BDI risk following anatomical misidentification could be reduced by intraoperative injection of isosulphan blue; further studies are required to validate the clinical utility of this technique. Keywords Laparoscopic cholecystectomy complications Bile duct injury prevention Isosulphan blue injection technique
Introduction Laparoscopic cholecystectomy (LC) represents the gold standard treatment for gallbladder removal; open cholecystectomy (OC) is performed only rarely, because LC confers advantages such as a shorter hospitalization period, more rapid return to normal activities, reduced postoperative pain, and good cosmetic outcomes. Furthermore, bile duct injuries (BDIs) are more common during OC [6, 18]. BDI can cause severe complications in LC patients, albeit the incidence is low (between 0.3 and 0.7 % of cases) [12]. BDI as a complication of LC may result in biliary cirrhosis, which is associated with considerable financial burden and increased mortality, and may require several consecutive operations and invasive procedures potentially leading to surgery anxiety. Such outcomes typically result from the inability to directly visualize bile ducts [10, 22, 25]. The most frequent cause of BDI is anatomical misidentification, particularly by inexperienced surgeons [12]. According to Strasberg et al. [23] to perform LC safely, the cystic artery, cystic duct, and gallbladder should be visualized during dissection of Calot’s triangle; peripheral identification of the cystic duct is particularly important.
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Surg Radiol Anat
Intraoperative cholangiography (IOC) is recommended in certain cases, for example, when choledochal stones are present [6]. It does not eliminate BDI, but may facilitate the intraoperative detection of injury and repair such that superior outcomes are achieved and mortality rates are reduced [1]. When detected during IOC after administering contrast agent and performing radiological imaging, cystic ducts should be dissected and cannulated. However, identification and dissection may not be possible due to inflammation and anatomical abnormalities, which may lead to BDI [15, 22, 25]. IOC is also associated with prolonged surgery duration, exposure to radiation, and greater equipment and personnel requirements [12]. Isosulphan blue (lymphazurin) is the monosodium salt of a 2,5 disulfonated triphenylmethane dye. The dye for the injection was prepared as a 1 % solution. Ten percent of isosulphan blue is excreted unchanged in the urine, and disappears completely from the urine samples after 24 h from the injection procedure. The stool is demonstrated to be stained dark blue after the injection in animal studies. Literature data are lacking with respect to any technical procedure in order to determine isosulphan blue levels in stool accurately. Ninety percent of the injected isosulphan blue was presumed to be excreted into the feces through biliary excretion. Phase II clinical trials have demonstrated no adverse effects, changes in vital signs, or significant biochemical findings in blood [5]. Isosulfan blue dye is used to stain the sentinel node(s) in order to detect malignant lymph node metastasis. Complications related with isosulphan blue have been reported in 1.5 % of the cases, primarily mild allergic reactions and a few cases of anaphylaxis. Transient skin discoloration related with isosulphan blue use (reversible in several hours to weeks) may result in a modest artifactual desaturation detected by pulse oximetry. Adequate oxygen saturation levels may be confirmed by arterial blood gas measurements in such situations. This reversible skin discoloration in patients has not shown to be associated with any clinical implications. The discoloration of some body secretions such as urine has also been found to be of no clinical significance [7, 24]. Isosulphan blue dye is currently used to visualize lymph nodes and lymphatic channels in breast, gastric, cervical, skin, and colon cancers. When administered peritumorally, or to the subareolar region during breast-conserving surgery, the dye follows the lymphatic channel and reaches the first sentinel lymph node to be metastasized; the channel and node are stained blue, allowing for the area to be mapped. Then, the detected lymph nodes are frozen, with treatment determined according to whether metastasis has occurred [4, 8, 16, 21].
123
A clear anatomical visualization of the biliary tract involving the cystic duct, common bile duct, and gallbladder by isosulphan blue injection during surgery may decrease BDI risk. In the present cadaveric study, we visualized the gallbladder, cystic duct, and bile duct by staining with isosulphan blue during LC, to assess whether this method allows for safe dissection of Calot’s triangle and reduced BDI incidence.
Materials and methods This study was conducted during 10 standard autopsies of fresh (\6 h since death) cadavers at the Council of Forensic Medicine, Istanbul. Victims of abdominal trauma were excluded. In daily clinical practice, hydropic gall bladders are punctured percutaneously through the fundus in order to drain a little amount of the content to grasp the bladder easily. The drainage of the residual gall bladder content is avoided by the closure of the punctured area by the endoscopic grasper (Fig. 1a, b). In a previous clinical study in which they stained the biliary tract with a different dye, the leakage of the residue of the gall bladder was prevented by the same technique [10]. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. A deep dissection was conducted in order to demonstrate the biliary tract visualized by isosulphan blue dye.
Results Of the 10 fresh cadavers, 3 were males and 7 were females; the mean age at death was 43 years (range 22–76 years). All cadavers of both sexes had gallstones. The gall bladder and the other parts of the biliary tract were stained by isosulphan blue in a few minutes following the dye injection. Since the dye was injected directly into the lumen of the biliary tract, it went through the lumen and reached the duodenum without spreading into the surrounding tissues. Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct was achieved in all of the cadavers (Fig. 2a–d). The gall bladder and the remaining biliary tract, primarily the connection of the cystic duct with the common bile duct are visualized clearly by means of this technique just before the dissection. Additionally, the clear borders of the gall bladder stained with dye provided the surgical removal of the organ without perforating (Fig. 3).
Surg Radiol Anat
Fig. 1 a, b All of the gallbladder bile was aspirated; isosulphan blue, equal in amount to the aspirated bile, was injected gradually into the gallbladder. The leakage of the residual gall bladder content is
avoided by the closure of the punctured area by the endoscopic grasper. GB gallbladder
Fig. 2 a–d The gallbladder, cystic duct, and common bile duct were identified with isosulphan blue dye during superficial (a) and deep (d) dissection. GB gallbladder, CD cystic duct, CBD common bile duct
Discussion BDI is among the most challenging complications of LC, for both surgeons and patients. It is associated with high morbidity and mortality rates; diagnosis can also be problematic and treatment may only be possible during a subsequent surgery. BDI is approximately twofold more frequent during LC than during OC, due to the reduced
sensorial information that characterizes LC (absence of tactile information and reliance on two-dimensional images), the application of inappropriate dissection principles and techniques, the absence of a strategy to ensure clear identification of the cystic duct, the inability or reluctance on behalf of the surgeon to visualize the bile duct, and indecision regarding the performance of an OC. Surgeons may also erroneously interpret atypical anatomy [18].
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Surg Radiol Anat
Fig. 3 The gallbladder can be clearly visualized since the margins are also stained
An inexperienced surgeon; severe, acute, or chronic gallbladder inflammation; fatty surgical sites; excessive bleeding; aberrant or rare anatomy; and/or the application of inappropriate surgical techniques may increase the likelihood of BDI. The most common cause of BDI is misidentifying, and subsequently clipping and incising, the common hepatic or bile duct, believing it to be the cystic duct (accounting for between 71 and 97 % of BDIs) [2]. Less common causes of BDI or biliary leakage include inappropriate closure of the cystic duct, choledochal damage following tenting, the opening of superficial intrahepatic bile ducts following deep dissection of the liver bed, and inappropriate use of electrocautery [18, 20]. BDI may result in prolonged hospitalization, increased morbidity and mortality, and legal liability. If BDI does occur, peroperative identification and repair represents the optimal method of reducing morbidity and mortality [10]. To minimize BDI risk during LC, the technical and visual–spatial deficiencies associated with laparoscopy must be surmounted; a number of surgical techniques can prove facilitative, in addition to assistance from another surgeon or performance of open surgery. Several methods have been suggested to improve anatomical visualization, including the ‘‘critical view of safety’’ approach [21], laparoscopic ultrasound, cholecystocholangiography, dye cholangiography, light cholangiography, infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. However, these methods are expensive, difficult to learn and perform, and do not involve clear, real-time images. [3, 9–11, 13, 14, 17, 19, 25]. In the isosulphan blue technique recommended in the present study, the gallbladder, ductus cysticus, and choledochus are stained minutes after administration of the dye into the gallbladder, such that the connection between the cystic and bile ducts can be visualized; this allows for safe and easy, deep dissection. The isosulphan blue technique
123
does not prolong surgery duration, and is easy to learn as well as economical, requiring neither additional equipment nor personnel. Furthermore, the gallbladder can be clearly visualized because its margins are also stained, facilitating gallbladder removal and avoiding liver bed perforation. Administered isosulphan blue is excreted by a nasogastric catheter, or by being passed into the duodenum. Dye leakage from the injury site allows for repair during the same surgical session using open surgery [10]. This technique is not yet supported by clinical trials; a further limitation pertains to the possibility of failure to stain the cystic and bile ducts if they are obstructed by a stone or inflammation. Nevertheless, the technique allows for realtime visualization of the gallbladder and cystic and bile ducts prior to dissection during LCs for cholecystitis with chronic stones and gallbladder polyps.
Conclusion This preliminary cadaveric study may lead to pioneering future clinical and experimental studies regarding the use of isosulphan blue dye in laparoscopic cholecystectomy in order to visualize the anatomy of extrahepatic biliary tract. Visualization of the biliary tract, using isosulphan blue dye, allows for safe dissection of Calot’s triangle. Surgical BDIs following anatomical misidentification may be reduced by this dyeing technique; further studies are required to validate its clinical utility. Acknowledgments We thank Prof. Dr. Fehmi Celebi and Associate Professor Fatih Altintoprak for comments that greatly improved the ¨ zkan for the review of the manuscript, also Prof. Dr. Sebiha O manuscript in terms of linguistic rules. Conflict of interest
The authors declare no conflicts of interest.
References 1. Alvarez FA, de Santiban˜es M, Palavecino M et al (2014) Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Br J Surg 101(6):677–684 2. Buddingh KT, Nieuwenhuijs VB, van Buuren L, Hulscher JB, de Jong JS, van Dam GM (2011) Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 25(8):2449–2461 3. Figueiredo JL, Siegel C, Nahrendorf M, Weissleder R (2010) Intraoperative near-infrared fluorescent cholangiography (NIRFC) in mouse models of bile duct injury. World J Surg 34(2):336–343 4. Gien LT, Kwon JS, Carey MS (2005) Sentinel node mapping with isosulfan blue dye in endometrial cancer. J Obstet Gynaecol Can 27(12):1107–1112 5. Hirsch JI, Tisnado J, Cho SR, Beachley MC (1982) Use of isosulfan blue for identification of lymphatic vessels: experimental and clinical evaluation. AJR Am J Roentgenol 139(6):1061–1064
Surg Radiol Anat 6. Iorga C, Cirimbei S, Strambu V, Popa F (2013) Intraoperative cholangiography still a current investigation. J Med Life 6(4):399–402 7. Leong SP, Donegan E, Heffernon W, Dean S, Katz JA (2000) Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol 7(5):361–366 8. Lumachi F, Norberto L, Zanella S et al (2011) Axillary node sampling in conjunction with sentinel node biopsy in patients with breast cancer. A prospective preliminary study. Anticancer Res 31(2):693–697 9. Mitra K, Melvin J, Chang S, Park K, Yilmaz A, Melvin S, Xu RX (2012) Indocyanine-green-loaded microballoons for biliary imaging in cholecystectomy. J Biomed Opt 17(11):116025 10. Sari YS, Tunali V, Tomaoglu K, Karago¨z B, Gu¨neyi A, Karago¨z I (2005) Can bile duct injuries be prevented? ‘‘A new technique in laparoscopic cholecystectomy’’. BMC Surg 17(5):14 11. Schols RM, Bouvy ND, Masclee AA, van Dam RM, Dejong CH, Stassen LP (2013) Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation. Surg Endosc 27(5):1530–1536 12. Schols RM, Bouvy ND, van Dam RM, Masclee AA, Dejong CH, Stassen LP (2013) Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy. Surg Endosc 27(12): 4511–4517 13. Schols RM, Lodewick TM, Bouvy ND et al (2014) Near-infrared fluorescence laparoscopy of the cystic duct and artery in pigs: performance of a preclinical dye. J Laparoendosc Adv Surg Tech A 24(5):318–322 14. Schnelldorfer T, Jenkins RL, Birkett DH, Georgakoudi I (2015) From shadow to light: visualization of extrahepatic bile ducts using image-enhanced laparoscopy. Surg Innov 22(2):194–200 15. Sheffield KM, Riall TS, Han Y, Kuo YF, Townsend CM Jr, Goodwin JS (2013) Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury. JAMA 310(8):812–820
16. Schwendinger V, Mu¨ller-Holzner E, Zeimet AG, Marth C (2006) Sentinel node detection with the blue dye technique in early cervical cancer. Eur J Gynaecol Oncol 27(4):359–362 17. Sherwinter DA (2012) Identification of anomalous biliary anatomy using near-infrared cholangiography. J Gastrointest Surg 16(9):1814–1815. doi:10.1007/s11605-012-1945-z 18. Soper NJ (2011) Prevention of biliary leaks. J Gastrointest Surg 15(6):1005–1006 19. Spinoglio G, Priora F, Bianchi PP et al (2013) Real-time nearinfrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc 27(6):2156–2162 20. Spinoglio G, Marano A (2013) Is the routine use of intraoperative cholangiography during laparoscopic cholecystectomy really the key to lowering bile duct injuries? Surg Endosc 27(12): 4748–4749 21. Thomas KA, Lechner J, Shen P, Waters GS, Geisinger KR, Levine EA (2006) Use of sentinel node mapping for cancer of the colon: ‘to map or not to map’’. Am Surg 72(7):606–611 (discussion 611–612) 22. To¨rnqvist B, Stro¨mberg C, Persson G, Nilsson M (2012) Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 11(345):e6457 23. Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125 24. Wear KD, Karsif K, Turner J (2003) Staining of endotracheal tube with isosulfan blue dye after sentinel node mapping: a case report. Breast J 9(1):47–48 25. Zuzak KJ, Naik SC, Alexandrakis G, Hawkins D, Behbehani K, Livingston E (2008) Intraoperative bile duct visualization using near-infrared hyperspectral video imaging. Am J Surg 195(4):491–497
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ANATOMIC BASES OF MEDICAL, RADIOLOGICAL AND SURGICAL TECHNIQUES
Visualizing biliary tracts with isosulphan blue to prevent injury during laparoscopic cholecystectomy: a preliminary cadaveric study Orhan Veli Ozkan1 • Orhan Yagmurkaya2 • Muhammed Feyzi Sahin3 Ahmet Selcuk Gurler3 • Hudaverdi Kucuker4
•
Received: 13 February 2015 / Accepted: 29 May 2015 Ó Springer-Verlag France 2015
Abstract Background Bile duct injury (BDI) as a complication of laparoscopic cholecystectomy may result in biliary cirrhosis with a high morbidity–mortality rate. Recurrent invasive procedures may be required for the optimum management. The most frequent causative factor in BDI is anatomical misidentification, particularly by inexperienced surgeons. Direct coloration of the cystic duct, bile duct, and gallbladder may decrease biliary tract injury. Methods This study was conducted during 10 standard, fresh cadaver autopsies at the Council of Forensic Medicine, Istanbul. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. Results Of the ten fresh cadavers, three were males and seven were females; the mean age at death was 43 years (range 22–76 years). Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct, was achieved in all of the cadavers. Conclusions Visualization of the biliary tract may reduce the risk associated with dissection of Calot’s triangle.
& Orhan Veli Ozkan [email protected] 1
Department of General Surgery, Faculty of Medicine, Sakarya University, Adnan Menderes Caddesi, Saglik Sokak No:193, 54100 Sakarya, Turkey
2
Department of General Surgery, Research and Educational Hospital, Sakarya University, 54100 Sakarya, Turkey
3
Council of Forensic Medicine, Bahc¸elievler, 34196 Istanbul, Turkey
4
Department of Forensic Medicine, Faculty of Medicine, Dumlupınar University, 43266 Sakarya, Turkey
Surgical BDI risk following anatomical misidentification could be reduced by intraoperative injection of isosulphan blue; further studies are required to validate the clinical utility of this technique. Keywords Laparoscopic cholecystectomy complications Bile duct injury prevention Isosulphan blue injection technique
Introduction Laparoscopic cholecystectomy (LC) represents the gold standard treatment for gallbladder removal; open cholecystectomy (OC) is performed only rarely, because LC confers advantages such as a shorter hospitalization period, more rapid return to normal activities, reduced postoperative pain, and good cosmetic outcomes. Furthermore, bile duct injuries (BDIs) are more common during OC [6, 18]. BDI can cause severe complications in LC patients, albeit the incidence is low (between 0.3 and 0.7 % of cases) [12]. BDI as a complication of LC may result in biliary cirrhosis, which is associated with considerable financial burden and increased mortality, and may require several consecutive operations and invasive procedures potentially leading to surgery anxiety. Such outcomes typically result from the inability to directly visualize bile ducts [10, 22, 25]. The most frequent cause of BDI is anatomical misidentification, particularly by inexperienced surgeons [12]. According to Strasberg et al. [23] to perform LC safely, the cystic artery, cystic duct, and gallbladder should be visualized during dissection of Calot’s triangle; peripheral identification of the cystic duct is particularly important.
123
Surg Radiol Anat
Intraoperative cholangiography (IOC) is recommended in certain cases, for example, when choledochal stones are present [6]. It does not eliminate BDI, but may facilitate the intraoperative detection of injury and repair such that superior outcomes are achieved and mortality rates are reduced [1]. When detected during IOC after administering contrast agent and performing radiological imaging, cystic ducts should be dissected and cannulated. However, identification and dissection may not be possible due to inflammation and anatomical abnormalities, which may lead to BDI [15, 22, 25]. IOC is also associated with prolonged surgery duration, exposure to radiation, and greater equipment and personnel requirements [12]. Isosulphan blue (lymphazurin) is the monosodium salt of a 2,5 disulfonated triphenylmethane dye. The dye for the injection was prepared as a 1 % solution. Ten percent of isosulphan blue is excreted unchanged in the urine, and disappears completely from the urine samples after 24 h from the injection procedure. The stool is demonstrated to be stained dark blue after the injection in animal studies. Literature data are lacking with respect to any technical procedure in order to determine isosulphan blue levels in stool accurately. Ninety percent of the injected isosulphan blue was presumed to be excreted into the feces through biliary excretion. Phase II clinical trials have demonstrated no adverse effects, changes in vital signs, or significant biochemical findings in blood [5]. Isosulfan blue dye is used to stain the sentinel node(s) in order to detect malignant lymph node metastasis. Complications related with isosulphan blue have been reported in 1.5 % of the cases, primarily mild allergic reactions and a few cases of anaphylaxis. Transient skin discoloration related with isosulphan blue use (reversible in several hours to weeks) may result in a modest artifactual desaturation detected by pulse oximetry. Adequate oxygen saturation levels may be confirmed by arterial blood gas measurements in such situations. This reversible skin discoloration in patients has not shown to be associated with any clinical implications. The discoloration of some body secretions such as urine has also been found to be of no clinical significance [7, 24]. Isosulphan blue dye is currently used to visualize lymph nodes and lymphatic channels in breast, gastric, cervical, skin, and colon cancers. When administered peritumorally, or to the subareolar region during breast-conserving surgery, the dye follows the lymphatic channel and reaches the first sentinel lymph node to be metastasized; the channel and node are stained blue, allowing for the area to be mapped. Then, the detected lymph nodes are frozen, with treatment determined according to whether metastasis has occurred [4, 8, 16, 21].
123
A clear anatomical visualization of the biliary tract involving the cystic duct, common bile duct, and gallbladder by isosulphan blue injection during surgery may decrease BDI risk. In the present cadaveric study, we visualized the gallbladder, cystic duct, and bile duct by staining with isosulphan blue during LC, to assess whether this method allows for safe dissection of Calot’s triangle and reduced BDI incidence.
Materials and methods This study was conducted during 10 standard autopsies of fresh (\6 h since death) cadavers at the Council of Forensic Medicine, Istanbul. Victims of abdominal trauma were excluded. In daily clinical practice, hydropic gall bladders are punctured percutaneously through the fundus in order to drain a little amount of the content to grasp the bladder easily. The drainage of the residual gall bladder content is avoided by the closure of the punctured area by the endoscopic grasper (Fig. 1a, b). In a previous clinical study in which they stained the biliary tract with a different dye, the leakage of the residue of the gall bladder was prevented by the same technique [10]. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. A deep dissection was conducted in order to demonstrate the biliary tract visualized by isosulphan blue dye.
Results Of the 10 fresh cadavers, 3 were males and 7 were females; the mean age at death was 43 years (range 22–76 years). All cadavers of both sexes had gallstones. The gall bladder and the other parts of the biliary tract were stained by isosulphan blue in a few minutes following the dye injection. Since the dye was injected directly into the lumen of the biliary tract, it went through the lumen and reached the duodenum without spreading into the surrounding tissues. Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct was achieved in all of the cadavers (Fig. 2a–d). The gall bladder and the remaining biliary tract, primarily the connection of the cystic duct with the common bile duct are visualized clearly by means of this technique just before the dissection. Additionally, the clear borders of the gall bladder stained with dye provided the surgical removal of the organ without perforating (Fig. 3).
Surg Radiol Anat
Fig. 1 a, b All of the gallbladder bile was aspirated; isosulphan blue, equal in amount to the aspirated bile, was injected gradually into the gallbladder. The leakage of the residual gall bladder content is
avoided by the closure of the punctured area by the endoscopic grasper. GB gallbladder
Fig. 2 a–d The gallbladder, cystic duct, and common bile duct were identified with isosulphan blue dye during superficial (a) and deep (d) dissection. GB gallbladder, CD cystic duct, CBD common bile duct
Discussion BDI is among the most challenging complications of LC, for both surgeons and patients. It is associated with high morbidity and mortality rates; diagnosis can also be problematic and treatment may only be possible during a subsequent surgery. BDI is approximately twofold more frequent during LC than during OC, due to the reduced
sensorial information that characterizes LC (absence of tactile information and reliance on two-dimensional images), the application of inappropriate dissection principles and techniques, the absence of a strategy to ensure clear identification of the cystic duct, the inability or reluctance on behalf of the surgeon to visualize the bile duct, and indecision regarding the performance of an OC. Surgeons may also erroneously interpret atypical anatomy [18].
123
Surg Radiol Anat
Fig. 3 The gallbladder can be clearly visualized since the margins are also stained
An inexperienced surgeon; severe, acute, or chronic gallbladder inflammation; fatty surgical sites; excessive bleeding; aberrant or rare anatomy; and/or the application of inappropriate surgical techniques may increase the likelihood of BDI. The most common cause of BDI is misidentifying, and subsequently clipping and incising, the common hepatic or bile duct, believing it to be the cystic duct (accounting for between 71 and 97 % of BDIs) [2]. Less common causes of BDI or biliary leakage include inappropriate closure of the cystic duct, choledochal damage following tenting, the opening of superficial intrahepatic bile ducts following deep dissection of the liver bed, and inappropriate use of electrocautery [18, 20]. BDI may result in prolonged hospitalization, increased morbidity and mortality, and legal liability. If BDI does occur, peroperative identification and repair represents the optimal method of reducing morbidity and mortality [10]. To minimize BDI risk during LC, the technical and visual–spatial deficiencies associated with laparoscopy must be surmounted; a number of surgical techniques can prove facilitative, in addition to assistance from another surgeon or performance of open surgery. Several methods have been suggested to improve anatomical visualization, including the ‘‘critical view of safety’’ approach [21], laparoscopic ultrasound, cholecystocholangiography, dye cholangiography, light cholangiography, infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. However, these methods are expensive, difficult to learn and perform, and do not involve clear, real-time images. [3, 9–11, 13, 14, 17, 19, 25]. In the isosulphan blue technique recommended in the present study, the gallbladder, ductus cysticus, and choledochus are stained minutes after administration of the dye into the gallbladder, such that the connection between the cystic and bile ducts can be visualized; this allows for safe and easy, deep dissection. The isosulphan blue technique
123
does not prolong surgery duration, and is easy to learn as well as economical, requiring neither additional equipment nor personnel. Furthermore, the gallbladder can be clearly visualized because its margins are also stained, facilitating gallbladder removal and avoiding liver bed perforation. Administered isosulphan blue is excreted by a nasogastric catheter, or by being passed into the duodenum. Dye leakage from the injury site allows for repair during the same surgical session using open surgery [10]. This technique is not yet supported by clinical trials; a further limitation pertains to the possibility of failure to stain the cystic and bile ducts if they are obstructed by a stone or inflammation. Nevertheless, the technique allows for realtime visualization of the gallbladder and cystic and bile ducts prior to dissection during LCs for cholecystitis with chronic stones and gallbladder polyps.
Conclusion This preliminary cadaveric study may lead to pioneering future clinical and experimental studies regarding the use of isosulphan blue dye in laparoscopic cholecystectomy in order to visualize the anatomy of extrahepatic biliary tract. Visualization of the biliary tract, using isosulphan blue dye, allows for safe dissection of Calot’s triangle. Surgical BDIs following anatomical misidentification may be reduced by this dyeing technique; further studies are required to validate its clinical utility. Acknowledgments We thank Prof. Dr. Fehmi Celebi and Associate Professor Fatih Altintoprak for comments that greatly improved the ¨ zkan for the review of the manuscript, also Prof. Dr. Sebiha O manuscript in terms of linguistic rules. Conflict of interest
The authors declare no conflicts of interest.
References 1. Alvarez FA, de Santiban˜es M, Palavecino M et al (2014) Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Br J Surg 101(6):677–684 2. Buddingh KT, Nieuwenhuijs VB, van Buuren L, Hulscher JB, de Jong JS, van Dam GM (2011) Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 25(8):2449–2461 3. Figueiredo JL, Siegel C, Nahrendorf M, Weissleder R (2010) Intraoperative near-infrared fluorescent cholangiography (NIRFC) in mouse models of bile duct injury. World J Surg 34(2):336–343 4. Gien LT, Kwon JS, Carey MS (2005) Sentinel node mapping with isosulfan blue dye in endometrial cancer. J Obstet Gynaecol Can 27(12):1107–1112 5. Hirsch JI, Tisnado J, Cho SR, Beachley MC (1982) Use of isosulfan blue for identification of lymphatic vessels: experimental and clinical evaluation. AJR Am J Roentgenol 139(6):1061–1064
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