Original CommunicationsNew strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots*
Section snippets
Why has surgical training failed to prevent bile duct injury?
A system approach to the continued high rate of bile duct injury requires an examination of the reasons why accepted surgical teaching about this problem seems to have failed. Such teaching falls into 2 categories: technical advice and general principles. Hunter6 has provided one of the best descriptions of technical steps useful in preventing bile duct injury, such as the use of a 30-degree telescope and methods of retraction and dissection in Calot's triangle. General surgical principles are
Bile duct injury and spatial disorientation
Misidentification of the biliary anatomy, usually mistaking a small common bile duct for the cystic duct, is the most common cause of bile duct injury. This was the mechanism in 27 (79%) of 34 cases referred to our unit; Olsen,19 in a review of 177 cases of bile duct injury in LC, found 71% were a result of misidentified anatomy and similar observations in open cholecystectomy were made by Way et al.9 This regularly repeated mechanism of error indicates that disorientating visual traps are an
Start from a fixed point
The traditional fixed starting point in open cholecystectomy is the fundus of the gallbladder—a “fundus first” cholecystectomy. The fundus-first technique is difficult to apply in LC as a result of loss of traction on the liver when the fundus is mobilized. An alternative reference point to guide the commencement of dissection is Rouvière's sulcus,20 a cleft in the liver running to the right of the hilum, visible in 78% of patients. The sulcus is partially fused in some patients, but with
Application of new strategies
The use of such modified navigation principles and extra-biliary reference points, along with “human factors” training, has been progressively applied in 2000 LCs carried out on 1 surgical unit between 1990 and 2001.
Patients and methods
A prospective study commenced in 1990 in which the above principles were progressively applied in a consecutive series of patients undergoing LC, including emergency and elective operations. The patient and operative data are shown in Table II.Empty Cell No. of patients Median age, y Grade 1 (%) Grade 2 (%) Grade 3 (%) Grade 4 (%) Acute cholecystitis (%) Gallstone pancreatitis (%) Trainee surgeon (%)
Results
Conversion to an open operation was required in 64 patients (3.2%).
There were no bile duct injuries. Eight patients had biliary leakage develop, resolving spontaneously in 3 patients with a drain in situ, and after percutaneous aspiration in 2 patients. Three patients had temporary insertion of an endoscopic stent to control biliary leakage. None of the 8 patients have had subsequent biliary problems, thus confirming the clinical and radiologic assessment that leakage was from the cystic duct
Human factors and bile duct injury
Although thorough instruction in the principles of safe surgical technique for cholecystectomy is essential and the application of navigational principles may be useful, it may be equally important to develop new training strategies that use knowledge of psychologic factors in the production of error. This is the human factors approach that has been applied effectively in what Reason4 describes as “high-reliability organizations” such as air-traffic control and the nuclear power industry.
Some
Conclusion
Bile duct injury remains the most significant complication of LC, occurring in 1 in 200 to 300 operations throughout the world. Traditional surgical teaching and a person approach of blame allocation have failed to reduce the frequency of this complication to acceptable levels. New strategies that draw on training in the aviation and maritime industries, the use of navigation-based principles, the application of a system approach, and the teaching of human factors in error prevention indicate
Acknowledgements
I thank Dr John Cartmill, who introduced me to the language of error. I am also grateful to Capt Geoff Tylor, senior training captain, Qantas Airways Training, Sydney, Australia, who not only made it possible for me to participate in a crew resource management course, but made me feel especially welcome. A special debt is owed to Prof G. D. Tracy, emeritus Professor of Surgery, St Vincent's Hospital, who participated in many of the operations and provided an invaluable sounding board for the
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Reprint requests: Thomas B. Hugh, FRCS, FRACS, Suite 1006, St Vincent's Clinic, 438 Victoria St, Darlinghurst NSW 2010, Australia.