Operative Strategy Can Reduce the Incidence of Major Bile Duct Injury in Laparoscopic Cholecystectomy

Major bile duct injury (BDI) rates remain in the range of 0.3 to 0.5 per cent for laparoscopic cholecystectomy (LC). The dominant surgical technique worldwide continues to be the "infundibular" technique of dissection that was popularized in the early 1990s. Proponents of the "critical view of safety" (CV) technique have suggested that most of these injuries are avoidable. The objective of our study was to determine whether routine use of the CV technique reduced the observed/expected single-institution rate of major BDI over a 5-year period in a teaching hospital. All patients (n = 3042) who underwent LC for any indication at one institution over a 60-month period were identified by database search. Major BDI was identified by Common Procedural Terminology codes indicating operative repair and confirmed by review of medical records. One patient sustained a transection-excision of the common duct requiring hepaticoduodenostomy. Based on published data, the observed BDI rate was one in nine to one in 15 of the expected rate. This represents an order-of-magnitude improvement in the safety of LC at a single institution where the majority of cases were performed by residents. We suggest that the "critical view" technique should be widely adopted.