[Conversion has to be learned: bile duct injury following conversion to open cholecystectomy]

In three patients, a man aged 52 years, a woman aged 35 years and a man aged 72 years, respectively, severe bile duct injury occurred following conversion from laparoscopic to open cholecystectomy. Treatment included percutaneous transhepatic drainage, abdominal drainage and bile return via a duodenal canula, and hepaticojejunostomy with Roux-and-Y reconstruction. Bile duct injury is the most significant complication following cholecystectomy, with substantial long term morbidity. The most common treatment for gallstones is laparoscopic cholecystectomy, irrespective of the presence of risk factors for conversion and bile duct injury. Generally, when the 'critical view of safety' cannot be obtained during laparoscopic cholecystectomy, conversion to open surgery is advocated to prevent bile duct injury. Surgical residents however, now have little or no experience with the open procedure. Conversion does not always provide a better view of the anatomy and, without experience with this procedure, it may even lead to more severe bile duct injury, such as transection or resection of the duct. In the case of a difficult laparoscopic cholecystectomy, a change of surgical strategy, such as antegrade or subtotal cholecystectomy or even drainage, may be more important than conversion per se.