Published online Feb 27, 2019. doi: 10.4240/wjgs.v11.i2.62
Peer-review started: November 14, 2018
First decision: November 29, 2018
Revised: January 6, 2019
Accepted: January 23, 2019
Article in press: January 23, 2019
Published online: February 27, 2019
Processing time: 107 Days and 4.4 Hours
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
Core tip: Laparoscopic cholecystectomy (LC) is associated with higher risk of biliary injury. This complication is associated with prolonged morbidity, decreased overall survival and potential for litigation. Prevention remains the best strategy. With the understanding of underlying mechanisms related to this complication, a number of preventive strategies have been described. Besides proper training and use of optimal equipment, understanding relevant anatomy, identification of factors predicting difficult procedure, execution of correct surgical technique, use of the critical view of safety, judicious use of energy sources, understanding stopping rules, time-out and bailout techniques, and proper documentation are basic tenets of safe LC.