Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy

Abstract

Many biliary misidentification injuries occur due to error traps-methods that work well in most circumstances but which are apt to under certain conditions. We have identified four such traps from an extensive experience in repair of biliary injuries. The most common cause of misidentification results from the “infundibular technique” error trap. This problem is usually associated with severe inflammation which hides the cystic duct and obliterates the triangle of Calot making the common hepatic duct appear to be part to the gallbladder wall. Another error trap — the “fundus-down” cholecystectomy has been associated with injuries in which the vascular component of the injury has been even more serious than the biliary one ie, “vasculo-biliary injuries” These vasulo-biliary injuries result in hepatic infarction requiring liver resection, possibly including transplantation. As opposed to the infundibular technique error trap the fundus down error trap usually occurs at open cholecystectomy after conversion. The two other error traps are due to failure to perceive the presence of an aberrant right hepatic duct on cholangiography and injury to the common bile duct in the case of a “parallel union” cystic duct. Knowledge of these error traps and their avoidance can help to reduce the incidence of biliary injuries.