Avoiding Misidentification Injuries in Laparoscopic Cholecystectomy: Use of Cystic Duct Marking Technique in Intraoperative Cholangiography

M C A t t c c c h b ile duct injuries continue to occur with disturbing freuency. In one recent series of over 56,000 patients rom Italy, 50% of 235 patients in whom bile duct injuies occurred were termed easy and 80% of patients had o risk factors, such as cholecystitis, listed. Nuzzo stated . . . no cholecystectomy can be considered as a simple outine procedure, immune to the risk of bile duct inury.” Strasberg and colleagues observed that in 81% of he cases they reviewed, the “. . . ‘cystic’ duct was isolated nd divided as the first step in the dissection of the riangle of Calot . . ..” In Way and colleagues series of 52 cases, 75% of operations were completed without he surgeon suspecting that an injury had occurred. ence the admonition, “Beware of the easy gallbladder.” Lack of a technique for proving conclusive anatomic dentity of the duct in question remains the problem to e solved. Way and colleagues stated, “. . . what is eeded is an even simpler method of locating the course f the ductal system during the operation, something impler than cholangiography or ultrasonography.” Cysic duct cholangiography has not been found to be uniormly successful in preventing bile duct injuries, espeially to aberrant right hepatic ducts, and has been eferred to as a “systems” problem. Mistaken identifiation of the common bile duct as the cystic duct results n a specific injury pattern and characteristic cholangioram, the so-called “cholangiogram of doom.” As Straserg states, “Mistaken cannulation of the common bile uct for the purpose of anatomic identification might ot be innocuous. It will, at the least, require conversion nd repair over a T-tube and, at worst, require biliary