Elsevier

Surgery

Volume 132, Issue 5, November 2002, Pages 826-835
Surgery

Original Communications
New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots*

https://doi.org/10.1067/msy.2002.127681Get rights and content

Abstract

Background. Injury to the bile ducts is the most important complication of laparoscopic cholecystectomy (LC), affecting approximately 2000 patients annually in the United States. Traditional surgical teaching fails to provide adequate extrabiliary reference points. A “person approach” of blame and shame (as distinct from a “system approach”) has evidently been unsuccessful in controlling this problem. New strategies are needed. High-reliability organizations such as aviation and the nuclear power industry have well-developed system-based error prevention programs; the application to laparoscopic operations of some principles used in these programs merits evaluation. In addition, some time-honored teaching of steps to safeguard the bile duct needs to be re-examined. Methods. A review of the literature and of 34 cases of bile duct injury referred to the author was carried out. Traditional surgical teaching was evaluated to identify reasons why it has failed to prevent bile duct injury. New extrabiliary reference points were used. Error prevention strategies derived from the aviation and maritime industries were modified for application to LC. These principles have been applied in a prospective study of 2000 successive LCs carried out on 1 surgical unit, including operations by surgical trainees. Results. The literature and case review indicated that misidentification of biliary anatomy was the major cause of bile duct injury and the injury was unrecognized by the operating surgeon in 3 out of 4 cases, suggesting that traditional surgical teaching provides inadequate reference points to prevent duct misidentification, that spatial disorientation analogous to navigation errors occurs, and that systemic factors predisposing to error are present. Several principles used in navigation were applied. “Human factors,” educational principles derived from aviation crew resource management training, were applied. No bile duct injuries occurred in the 2000 LC operations. Eight patients had biliary leakage develop but all recovered without further surgical intervention. Conclusions. Laparoscopic bile duct injury continues to occur at an unacceptable rate. New strategies involving a system approach and using principles adopted by the aviation and maritime industries were applied in 2000 consecutive LCs without bile duct injury. The application in the operating room of commonly taught navigation principles, the use of extrabiliary reference points such as Rouvière's sulcus, and the introduction of human factors education for surgeons reduces the frequency of bile duct injury. (Surgery 2002;132:826-35.)

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.

. Patient and operation data in 2000 consecutive laparoscopic cholecystectomies without bile duct injury, 1990 to 2001

Empty CellNo. of patientsMedian age, yGrade 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

References (29)

  • LW Way et al.

    Biliary stricture

    Surg Clin North Am

    (1981)
  • MS Woods et al.

    Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study

    Am J Surg

    (1994)
  • DC Wherry et al.

    An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense

    Ann Surg

    (1996)
  • SM Strasberg et al.

    An analysis of the problem of biliary injury during laparoscopic cholecystectomy

    J Am Coll Surg

    (1995)
  • LH Blumgart et al.

    Benign bile duct stricture following cholecystectomy: critical factors in management

    Br J Surg

    (1984)
  • J. Reason

    Human error: models and management

    Br Med J

    (2000)
  • MJ. Lerner

    The desire for justice and reactions to victims

  • JG. Hunter

    Avoidance of bile duct injury during laparoscopic cholecystectomy

    Am J Surg

    (1991)
  • BJ Carroll et al.

    Routine cholangiography reduces sequelae of common bile duct injuries

    Surg Endosc

    (1996)
  • CH Wakefield et al.

    Bile duct injury during laparoscopic cholecystectomy without operative cholangiography [letter]

    Br J Surg

    (1998)
  • DR Fletcher et al.

    Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography

    Ann Surg

    (1999)
  • AJ Richardson et al.

    Injuries to the bile duct resulting from laparoscopic cholecystectomy

    Aust N Z J Surg

    (1993)
  • A Andren-Sandberg et al.

    Accidental lesions of the common bile duct at cholecystectomy

    Ann Surg

    (1985)
  • JS Barkun et al.

    Cholecystectomy without operative cholangiography

    Ann Surg

    (1993)
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    Reprint requests: Thomas B. Hugh, FRCS, FRACS, Suite 1006, St Vincent's Clinic, 438 Victoria St, Darlinghurst NSW 2010, Australia.

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