A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Abstract Purpose Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury. Methods A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o’clock position as cranial, 6-o’clock as dorsal, 9-o’clock as caudal, and 12-o’clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images. Results All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o’clock position, 6-o’clock position, 9-o’clock position, 12-o’clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o’clock and 12-o’clock position were pitfalls that might cause biliary injury. Conclusion The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

摘要
目的 胆道损伤（Bile Duct Injury, BDI）是胆囊切除术的灾难性并发症，胆囊解剖结构误认被认为是其主要致病原因。尽管已开发出多种预防BDI的技术，如“安全关键视野（critical view of safety）”法、漏斗部技术（infundibular technique），但腹腔镜胆囊切除术（laparoscopic cholecystectomy, LC）的BDI发生率仍高于开放手术。本研究提出一种实用的新型胆管识别策略，可助力预防腹腔镜胆道损伤。
方法 本研究为单中心回顾性研究，纳入2007年3月至2019年2月期间于单中心接受LC的5539例患者。以胆囊颈作为表盘中心点，将胆囊漏斗部以虚拟时钟方位进行分类：3点钟方位为头侧、6点钟方位为背侧、9点钟方位为尾侧、12点钟方位为腹侧，并同步记录其轴向位置。收集患者人口统计学资料、病理学变量及胆囊漏斗部分类信息，本研究针对基于胆囊漏斗部方位的胆管识别开展详细分析，所有漏斗部方位均通过术中腹腔镜视频或摄影图像进行记录。
结果 本研究期间所有患者均顺利完成LC，无中转开腹手术或胆道损伤等严重并发症发生。胆囊漏斗部位于3点钟、6点钟、9点钟、12点钟方位及轴向位置的患者占比分别为12.3%、23.4%、28.0%、4.2%及32.1%。其中3点钟与12点钟方位为可能引发胆道损伤的风险位点。
结论 以胆囊漏斗部作为导航标志，可有效辅助胆管识别，降低BDI发生率，提升LC手术的安全性。