Prevention of bile duct injury - A bird's eye view

Gallstone disease is a common ailment and laparoscopic cholecystectomy (LC) is the most commonly performed surgical procedure for the treatment of symptomatic gallstones. Bile duct injury (BDI) is a serious complication reported in 0.1% to 0.2% and 0.15% to 0.36% of patients undergoing open and LC, respectively. The higher incidence of BDI following LC is a matter of grave concern that needs redressal. The cause and mechanism of BDI can be classified into gallbladder, patient or surgeon-related factors. Variable anatomy or inflammatory obliteration of the hepatocystic triangle (HCT), male sex, obese patient are some for the important causes for difficult cholecystectomy. A thorough pre-operative evaluation, delineation of anatomy in HCT to establish critical view of safety (CVS), alternative "bailout" techniques when CVS is not achievable, and use of intra-operative cholangiogram are considered the important strategies in performing safe cholecystectomy. Consensus guidelines have evolved in several multicentric studies to perform safe cholecystectomy with respect to prevention of BDI. The merits of CVS have been validated globally and recommended as the single most important factor in this regard. Surgeons strictly adhering to the CVS guidelines report significant reduction in the incidence of BDI. In this article, the predictors of difficult cholecystectomy, salient features of the technique of safe cholecystectomy, the bailout strategies and the role of intra-operative cholangiogram have been discussed. The suggested recommendations in this article are based on detailed review of the available literature and the guidelines suggested by several international societies.