J Hepatobiliary Pancreat Sci (2019) 26:123–127

DOI: 10.1002/jhbp.616

REVIEW ARTICLE

A three-step conceptual roadmap for avoiding bile duct injury in

laparoscopic cholecystectomy: an invited perspective review
Steven M. Strasberg

© 2019 Japanese Society of Hepato-Biliary-Pancreatic Surgery

Abstract Bile duct injuries are the most common serious
complication of cholecystectomy. Avoidance of bile duct
injury is a key aim of biliary surgery. The purpose of this
paper is to describe laparoscopic cholecystectomy from the
viewpoint of three conceptual goals. Three conceptual goals
of cholecystectomy are: (1) getting secure anatomical
identification of key structures; (2) making the right decision
not to perform a total cholecystectomy when conditions are
too dangerous to get secure identification – the “inflection
point”; and (3) finishing the operation safely when secure
anatomical identification of cystic structures is not possible.
The Critical View of Safety (CVS) has been shown to be a
good way of getting secure anatomical identification.
Conceptually, CVS is a method of target identification, the
targets being the two cystic structures. Sometimes, anatomic
identification is not possible because the risk of biliary injury
is judged to be too great. Then a decision is made to
abandon the attempt to do a complete cholecystectomy – and
instead to “bail-out”. This “inflection point” is defined as the
moment at which the decision is made to halt the attempt to
perform a total cholecystectomy laparoscopically and to
finish the operation by a different method. Currently the best
bail-out procedure seems to be subtotal fenestrating
cholecystectomy. Application of conceptual goals of
cholecystectomy can help the surgeon to avoid biliary injury.
Keywords Acute cholecystitis Bile duct injury Biliary
 
colic Biliary injury Cholecystectomy Critical view of
   biliary injury. Three conceptual goals (Fig. 1) will be dis-
safety Inflection point Laparoscopic cholecystectomy
   cussed as follows: (1) getting secure anatomical identifica-
Subtotal cholecystectomy Subtotal fenestrating
 tion whenever conditions permit; (2) knowing when
cholecystectomy Subtotal reconstituting cholecystectomy
 conditions are too dangerous to get secure identification
S. M. Strasberg (✉)
Section of Hepato-Pancreato-Biliary Surgery, Siteman Cancer
Center, Barnes-Jewish Hospital and Washington University School
of Medicine, 660 South Euclid Avenue, Box 8109, St. Louis, MO
63110, USA
e-mail: strasbergs@wustl.edu
Introduction
The gallbladder is a relatively unimportant organ. Some
mammalian species do not even have one [1]. But the
gallbladder is situated close to vital anatomic structures
that transport bile from the liver and supply blood to it.
Resection of the gallbladder by laparoscopic cholecys-
tectomy is one of the most common operations per-
formed today. It is an operation with a wide range of
difficulty. At the “easy” end of the spectrum, it is a
straightforward procedure that usually can be completed
in an hour. At the “tough” end, cholecystectomy can be
very challenging. Laparoscopic cholecystectomy is also
the most frequent cause of bile duct injury, which tends
to occur when the operation is difficult as a result of
inflammation [2].
Bile duct injuries are the most common serious compli-
cation of cholecystectomy. They are often very morbid
and may lead to death. Frequently they result in additional
surgeries, long recovery time, loss of time from work, and
diminution of quality of life [3]. Also, these injuries com-
monly result in litigation. Avoidance of bile duct injury is
a key goal of biliary surgery.
The purpose of this paper is to describe laparoscopic
cholecystectomy from the viewpoint of conceptual goals.
It is intended to provide a guide of how to think about
goals of laparoscopic cholecystectomy and thereby avoid
and making the decision not to perform a total cholecys-
tectomy laparoscopically – what we will call reaching the
“inflection point”; and (3) finishing the operation safely
when secure anatomical identification is not possible
(“bail-out” procedures).
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Step 1. Getting secure anatomical identification
whenever conditions permit
Most major bile duct injuries are due to misidentification.
Therefore, secure anatomic identification of the cystic duct
and cystic artery are the key goals of dissection. Although
other biliary and vascular structures may be displayed dur-
ing dissection, it is secure identification of the cystic duct
and cystic artery that are needed, since these are the struc-
tures that must be divided in cholecystectomy. It is well
known that in the “classical injury” [4], the common bile
duct is mistaken to be the cystic duct and is divided.
Aberrant hepatic ducts may also be mistakenly identified
as the cystic duct or cystic artery.
The Critical View of Safety (CVS) is a method whose
sole aim is secure identification of the cystic structures
[5, 6]. Today CVS is taught and used widely [7]. To
achieve CVS three requirements must be met have been
published [5, 6]. First, the hepatocystic triangle must be
cleared of fat and fibrous tissue. It does not require that
the common bile duct be exposed. Secondly the lowest
part of the gallbladder must be separated from the cystic
plate. The third requirement is that two structures, and
only two, should be seen entering the gallbladder. Only
when these three criteria are met, has CVS been attained.
Evidence indicates that CVS is an effective method of
anatomic identification in cholecystectomy. Reports con-
taining several thousand patients in which CVS was used
without a biliary injury due to misidentification have been
published [8, 9]. Based on an incidence of biliary injury
of 3–4/1,000 cases, one would expect about 20 biliary
injuries. Secondly, in studies of major biliary injury, CVS
has rarely been described as the method of anatomic iden-
tification that was used [4, 10].
Conceptually, CVS is a method of target identification,
the targets being the two cystic structures. CVS is not a
method of dissection, although the surgeon must use care-
ful dissection to display CVS. There are close parallels
with this duo of dissection and target identification in the
world of firearms use, for instance in game hunting and
the military. Accidents due to misidentification in these
fields are well described and they may lead to injury and
death. The equivalent to dissection in hunting is stalking.
J Hepatobiliary Pancreat Sci (2019) 26:123–127
Fig. 1 Three conceptual steps for
avoidance of biliary injury
Stalking places the hunter into the position where he can
make target identification just as dissection puts the sur-
geon into the position of displaying the CVS. The equiva-
lent to CVS in the firearms analogy are the criteria used
for determining that the target has been identified as
secure. For instance, for reasons of safety, deer hunting
regulations stipulate that hunters must identify the head
and torso of the deer before firing [11], as opposed to
shooting after seeing only the legs of an animal, since at
a distance human legs have been mistaken to be the legs
of deer with predicable outcome. The head and torso of
the animal are the CVS in hunting.
It is important for the surgeon to separate dissection
and identification in his or her mind. Dissection is tempo-
rally linear but target identification is temporally static.
Dissection reveals the CVS, but affirmation that the CVS
has been achieved takes place in a moment of time when
no dissection is going on. The stoppage is momentary
during which time the surgeon confirms that the critical
view is present. Confirmation of CVS may be in the sur-
geon’s own mind or the surgeon may point it out in a
“time out”, which is an appropriate step in a teaching situ-
ation. Also, there is an opportunity to record the CVS in
still photos [12] or by videotapes [13].
Step 2. Knowing when conditions are too dangerous to
get secure identification and making the decision not
to perform a total cholecystectomy laparoscopically –
reaching the “inflection point”
Every gallbladder surgeon knows that there is a large
range of difficulty in displaying anatomic structures dur-
ing cholecystectomy. On the one hand sometimes the cys-
tic duct and artery may be immediately visible upon
initial retraction of the gallbladder. The time needed to
dissect the hepatocystic triangle and meet the criteria for
CVS will likely be short. On the other hand, local and
patient factors may make dissection difficult and
prolonged. The dominant local factor affecting operative
difficulty is inflammation. Some other local factors are
aberrant anatomy and prior right upper quadrant surgery.
Patient factors include patient size, skeletal deformity, and
liver disease.
J Hepatobiliary Pancreat Sci (2019) 26:123–127
Both acute inflammation and chronic inflammation
increase operative difficulty. Acute inflammation hinders
dissection due to tissue swelling and increased tissue vas-
cularity. Chronic inflammation causes tissue fusion (adhe-
sion) and contraction. We examined predictors of
operative difficulty in acute cholecystitis [14]. The stron-
gest predictors were white blood cell count, male gender
and age. One can readily understand how elevated white
blood cell count would be predictive of marked local
inflammation in acute cholecystitis. However, it was not
apparent how male gender and age would act as predic-
tors of acute inflammation. The answer is that they were
probably not predictors of acute inflammation but of con-
comitant chronic inflammation in patients with acute
cholecystitis. One clue to this possibility was that male-
ness and age have both been repeatedly shown to be risk
factors for conversion in elective cholecystectomy, i.e. in
circumstances in which the diagnosis is not acute chole-
cystitis but chronic cholecystitis [15–17]. A second clue
was that reasons given for conversion in acute cholecysti-
tis often refer to contraction of tissues [18] and dense
adhesions [18–22] which are appropriate descriptors for
chronic inflammation. There are of course other conditions
briefly alluded to above that harden laparoscopic chole-
cystectomy. One such condition is severe contractive
chronic inflammation, which can result in shrinkage of the
gallbladder to one third its original size within months of
an attack of acute cholecystitis [23]. Recently the “Pucker
sign” a preoperative radiological indicator of impending
operative difficulty due to such severe rapidly evolving
chronic contractive inflammation was described [23].
A new term: the “inflection point” of a laparoscopic
cholecystectomy
Increasing operative difficulty is associated with increased
risk of injury to bile ducts, hepatic arteries and portal
veins. To avoid these the surgeon continuously judges the
level of risk of injury against the importance of fulfilling
the goal of the procedure. The aim of dissection is to get
to anatomic identification and complete the cholecystec-
tomy but the risk of persistence in adverse conditions is
that injury may occur [24]. Sometimes the risk is judged
to be too great and a decision is made to “bail-out”, i.e.
to abandon the attempt to do a complete laparoscopic
cholecystectomy. To avoid biliary injury, it is essential
that that decision is taken before injury occurs. But a pre-
cise formulation of what should go into the decision to
bail-out has not been made. One reason for this is that a
clear term is lacking for that exact decision point at
which the conclusion is made that the goal of the
operation should be changed from total laparoscopic
125
cholecystectomy to some other endpoint. The term “inflec-
tion point” commonly means “a turning point” or “a time
of significant change in a situation”. This term seems
appropriate for the situation faced in difficult cholecystec-
tomy. Thus, inflection point in cholecystectomy is defined
as the moment or the point in time at which the decision
is made to halt the attempt to perform a total cholecystec-
tomy laparoscopically and to finish the operation by a dif-
ferent method.
Since biliary injuries have occurred by persistence in
dissection in the face of adverse conditions there is a need
for studies to define under which circumstances and when
the inflection point should occur. Such studies might well
be more about surgeon decision making and behavior then
about local inflammatory conditions [25]. However, one
may make a few comments about inflection point. It
reflects a decision that made by the surgeon in a moment
in time. Depending on experience, training and other
surgeon factors the inflection point may differ among
surgeons. For instance, under difficult operative conditions
calling a surgical colleague to the operating room (when
possible) is recognized good practice. That surgeon may
agree that the inflection point has been reached or feel that
additional dissection is still safe or that cholangiography
should be performed before deciding to change the goals
of the procedure. The mindset regarding inflection point
should be that it is far superior to reach the inflection
point than to have a biliary injury. Also deciding to inflect
away from laparoscopic total cholecystectomy should be
considered as a wise choice applied under difficult condi-
tions. Finally, it seems sure that there is much more to be
learned about what governs the inflection point.
Step 3. Finishing the operation safely when secure
anatomical identification is not possible
For many years the bail-out procedure used when the
inflection point had been reached either in laparoscopic or
open cholecystectomy was a surgical tube cholecys-
tostomy (Fig. 1). That operation was followed in many
cases by a later second procedure to remove the gallblad-
der. Subtotal cholecystectomy, a one-stage bail-out proce-
dure for a difficult cholecystectomy, obviates the need for
a second operation. It was actually performed in 1898 by
Kehr [26], and papers supporting its use can be found up
to the 1950s [27]. However, it seems to have fallen out of
favor about mid-20th century. Standard surgical texts after
that time give little or no information on the procedure,
until recently when it has been revived [28]. Thus, most
surgeons were trained either to complete a cholecystec-
tomy or to perform a tube cholecystostomy and then a
second, often difficult cholecystectomy. The lack of a
126
bail-out procedure that could reliably deal with the dis-
eased gallbladder in a single stage was probably a strong
impetus for surgeons to push on in the face of a difficult
gallbladder operation, possibly increasing the risk of bil-
iary injury. It is not certain why subtotal cholecystectomy
fell out of favor in the mid-1900s but it is likely that the
risk of a prolonged postoperative biliary fistula, in the
days before endoscopic sphincterotomy was available,
deterred the use of this procedure. Prior to endoscopic
sphincterotomy persistent biliary fistula would require
reoperation. The resurgence of this operation [28] seems
to coincide with the availability of endoscopic retrograde
cholangiopancreatography-guided endoscopic sphinctero-
tomy, which provides a good method for treatment of
postoperative biliary fistula, should it occur. Thus, sur-
geons now have an operation, which can be performed
when the inflection point is reached that will at most
require an endoscopic procedure instead of reoperation to
close a biliary fistula. Conceptually this permits the sur-
geon to reach an inflection point earlier and at a lower
risk of biliary injury.
Bail-out options
While subtotal cholecystectomy is the best bail-out proce-
dure when the inflection point is reached it is also not
always possible. Broadly speaking operative conditions
leading to inflection may be divided into three types, each
requiring a different bail-out procedure.
Gallbladder cannot be found – very uncommon
The least common but most difficult situation is when the
gallbladder has undergone severe contractive inflamma-
tion. As we have recently shown, the gallbladder may
contract to less than one-third of its original size within
months of an attack of acute cholecystitis [23]. This sev-
ere contraction pulls adjacent organs such as the liver,
colon and stomach down onto the gallbladder making
exposure of even the dome of the gallbladder very diffi-
cult. In the operative notes of such operations, surgeons
will often state that they were unable to find the gallblad-
der after a sustained trial of dissection. Dealing with such
a gallbladder would seem to require a lot of experience in
bile duct and liver surgery. Therefore, the best bail-out
option for this rare situation may be to conclude the
laparoscopic procedure and refer the patient appropriately.
Only the dome of the gallbladder can be exposed –
uncommon
The second situation, which is also quite uncommon,
occurs when only the uppermost part of the gallbladder
J Hepatobiliary Pancreat Sci (2019) 26:123–127
can be exposed after a trial of dissection. Sometimes fur-
ther exposure is made difficult by the presence of chole-
cysto-colic or cholecysto-duodenal fistula or such tight
adhesion of colon or duodenum to the gallbladder is pre-
sent that enterotomy is imminent or has occurred. The
appropriate choice of procedure in these circumstances is
a cholecystostomy with stone extraction. This can often
be done laparoscopically. Subsequent management may
be interval cholecystectomy or percutaneous stone extrac-
tion if stones are still present, followed by removal of the
tube once stone extraction is completed and there is free
flow of contrast through the bile duct into the duodenum.
Hepatocystic triangle can be reached but CVS not
attained after trial of dissection
The third situation, which is much more common, occurs
when dissection in hepatocystic triangle fails to obtain
anatomical identification. Under these circumstances,
subtotal cholecystectomy is the procedure of choice today.
We introduced the terms subtotal reconstituting cholecys-
tectomy and subtotal fenestrating cholecystectomy in 2016
in an attempt to clarify confusing terminology which was
delaying progress in this field [29]. These terms have now
been adopted widely and have enabled studies comparing
the two types of subtotal cholecystectomy. The reconsti-
tuting type removes most of the gallbladder but closes off
the lower gallbladder so that a new small remnant gall-
bladder remains. In the fenestrating type the surgeon
removes the peritonealized surface of the gallbladder,
ablates the residual mucosa of the remaining gallbladder,
and, when possible, sutures the cystic duct from the inside
of the gallbladder. The disadvantage of the reconstituting
type is that new gallstones may form in the remnant
gallbladder and require a subsequent excision of the
remnant gallbladder. The disadvantage of the fenestrated
type is that it may lead to a biliary fistula that requires
endoscopic retrograde cholangiopancreatography and
endoscopic sphincterotomy. A study has been published
comparing the two types retrospectively [30] and other
studies are underway.
Conversion is not a bail-out procedure
Conversion alone is not a bail-out procedure from laparo-
scopic cholecystectomy, but rather the bail-out procedure
includes what is done after conversion. The choices of
procedure are open cholecystectomy, open subtotal chole-
cystectomy, cholecystostomy or just abdominal closure in
the rare instances in which the gallbladder can still not be
exposed. More than 30 years have passed since the first
laparoscopic cholecystectomy was performed. The skills
built up by surgeons in performing open cholecystectomy
J Hepatobiliary Pancreat Sci (2019) 26:123–127
by doing many open cholecystectomies during training
are no longer attainable during residency and the cadre of
surgeons trained before 1990 is diminishing rapidly. Sur-
geons trained in recent years may feel uncomfortable
undertaking an open cholecystectomy when the gallblad-
der could not be removed laparoscopically. This is caus-
ing a shift away from conversion as a step to be taken at
the inflection point of a laparoscopic cholecystectomy and
a shift toward laparoscopic subtotal cholecystectomy. If
subtotal cholecystectomy is not feasible laparoscopically
then conversion can be undertaken with the intention of
performing a subtotal rather than a total cholecystectomy.
In summary laparoscopic cholecystectomy can be con-
sidered to have three conceptual steps. Application of the
concepts described in this perspective review will aid the
surgeon to avoid biliary injury.
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