Avoiding misidentification injuries in laparoscopic cholecystectomy: use of cystic duct marking technique in intraoperative cholangiography.

摘要

Bile duct injuries continue to occur with disturbing frequency. In one recent series of over 56,000 patients from Italy, 50% of 235 patients in whom bile duct injuries occurred were termed easy and 80% of patients had no risk factors, such as cholecystitis, listed. Nuzzo stated ". . . no cholecystectomy can be considered as a simple routine procedure, immune to the risk of bile duct injury." Strasberg and colleagues observed that in 81% of the cases they reviewed, the "... 'cystic' duct was isolated and divided as the first step in the dissection of the triangle of Calot . ..." In Way and colleagues series of 252 cases, 75% of operations were completed without the surgeon suspecting that an injury had occurred. Hence the admonition, "Beware of the easy gallbladder." Lack of a technique for proving conclusive anatomic identity of the duct in question remains the problem to be solved. Way and colleagues stated, "... what is needed is an even simpler method of locating the course of the ductal system during the operation, something simpler than cholangiography or ultrasonography." Cystic duct cholangiography has not been found to be uniformly successful in preventing bile duct injuries, especially to aberrant right hepatic ducts, and has been referred to as a "systems" problem. Mistaken identification of the common bile duct as the cystic duct results in a specific injury pattern and characteristic cholangiogram,the so-called "cholangiogram of doom." As Strasberg states, "Mistaken cannulation of the common bile duct for the purpose of anatomic identification might not be innocuous. It will, at the least, require conversion and repair over a T-tube and, at worst, require biliaryreconstruction." An alternative, cholecystocholangiography,has the advantage of accessing the biliary system through the gallbladder and avoiding the problems inherent in small duct access and identification. Small duct anatomy, even if previewed with a cholangiogram, can be confusing. This is especially true if the gallbladder and cystic duct are fibrosed to the common hepatic duct. The problem can be overcome by placing radiopaque external reference markers next to the proposed "cystic duct" and linking the anatomy of the dissection to the image of the cholangiogram, thus orienting the surgeon. Conclusive proof of anatomic identity is obtained, avoiding misidentification injuries. This technique also has the advantage of detection of aberrant right hepatic duct anatomy and confusing cystic duct variations at an early stage of dissection. The first step in dissection of the triangle of Calot is marking the proposed "cystic duct," not dividing it, avoiding the "error trap" of the infundibular technique. The cystic duct marking technique focuses the surgeon on proving the identity of the duct and gives him a tool to complete the anatomic proof. The method differs from traditional cholecystocholangiography, where no dissection of the cystic duct occurs before the cholangiogram is performed. The technique can be thought of as a radiologic equivalent of fundus down dissection.