A new method of preventing bile duct injury in laparoscopic cholecystectomy

Of all the complications of laparoscopic cholectecystomy, bile duct injury (BDI) is the most serious complication. The prevention of injury to the common bile duct (CBD) remains a significant concern in laparoscopic cholecystectomy (LC). Different kinds of methods have been advanced to avoid this injury but no single method has gained wide acceptance. Because of various limitations of current methodologies we began a study using cold light illumination of the extrahepatic biliary system (light cholangiography LCP) to better visualize this area and thereby reduce the risk of bile duct injury.

Thirty-six patients with cholelithiasis were divided into two groups. Group I (16 cases) received LCP and group II (20 cases) received methelenum coeruleum cholangiography (MCCP). In group I cold light was used to illuminate the common bile duct by leading an optical fiber into the common duct with a duodenoscope at the time of LC. The light coming from the fiber in the CBD could clearly illuminate the location of CBD and hepatic duct establishing its location relative to the cystic duct. This method was compared with the dye injection technique using methelenum coeruleum.

In group I thirteen cases were successfully illuminated and three failed. The cause of three failed cases was due to the difficulty in inserting the fiber into the ampulla of Vater. No complications occurred in the thirteen successful cases. In each of these successful cases the location of the common and hepatic ducts was clearly seen differentiating the ductal system from surrounding anatomy. In ten cases both the left and right hepatic ducts could be seen and in three only the right hepatic ducts were seen. In four of the thirteen cases, cystic ducts were also seen. In group II, eighteen of the twenty cases were successful. The location of extrahepatic ducts became blue differentiating the ductal system from surrounding anatomy. Two cases failed due to a stone obstructing the cystic duct, and extravisation of the dye turned the entire area blue. LCP showed the common and hepatic ducts more clearly than MCCP.

LCP is the only technique that can clearly and directly show the location of the extrahepatic biliary system and may be useful in selecting cases of uncertain anatomy in the prevention of bile duct injury.