With the use of laparoscopy to treat gallbladder pathologies, there was an increase of bile duct injury (BDI) cases. Nowadays, there is a known 0,4% bile duct injury rate during laparoscopic cholecystectomy (LC). This is a major complication that can result in the need of major reconstructive surgery, which can have a great negative impact in Q-o-L of patients, and negative professional and psychological consequences for doctors. In this setting, every efforts to reduce BDI rate during LC are wellcome.
The "mainstay of management of BDI is prevention". The principal cause of BDI is a misidentification of structures. Because of that, many operative techniques have been reported to help the surgeon identify the common bile duct.
Intraoperative cholangiography - lack of evidence supporting its systematic use (contradictory findings, time consuming, cumbersome)
Fluorescence cholangiography - needs new equipment, injection of product, still in study
Critical view of Strasberg - can be difficult in severe acute or chronic inflammation
Retrograde approach ("fundus first") - can be useful in obese patients
From those techniques, the critical view of Strasberg is the most used one, and became an important tool to help the surgeon avoid BDI. The critical view of Strasberg is a "must do" - or "must view" - during LC. Even though, BDI still occurs in about 0,4% of LC. How to avoid it? Is there other technique that can help us?
"The mainstay of management of BDI is prevention."
Ferzli et al.
A retrospective analysis of a standard approach for LC over a 5-year period was conducted by George Ferzli et al from New York and Graz (USA and Austria, respectively). The aim of the study was to confirm the use of Node of Calot (Lund's Node or Mascagni's Lymph node) as a key landmark to reduce BDI avoiding close dissection to the common bile duct. A total of 907 LC were included (813 non-acute cases, 93 acute cholecystitis).
The authors' first step during LC is to identify the Node of Calot. Anatomically the node is anterior to the cystic artery (it "rides" the cystic artery), is lateral to the common bile duct and superior to the cystic duct. After identification of the node the authors can grasp the infundibulum safely. The fundamental step of the technique is to "stay caudal and lateral to the node" during dissection near the infundibulum. In this way the surgeon stays aways from an danger area cephalad to the node where injury to the common bile duct, hepatic duct or right hepatic artery can occur (Figure). Cystic artery is always underneath the Node of Calot, and cystic duct is lateral/inferior to it. Once critical view of Strasberg has been achieved (two structures entering the gallbladder), cystic duct and cystic artery can be ligated. (I strongly advise reading the standard approach described by the authors).
With the identification of the Node of Calot it is possible to delineate and not violate a danger zone cephalad to the node.
According to the authors, the critical view of safety (critical view of Strasberg) is essential to correct identification of structures, but the Node of Calot is an important landmark that is always present and is rarely taken into account. However, it can be of good help. Why? Even with severe inflammation the node is always readily identified. Additionally, with the identification of the Node of Calot it is possible to delineate and not violate a triangle danger zone cephalad to the node, limited medially by the common hepatic duct and superiorly by the liver (Figure). In this way, surgeon can avoid hepatic duct, common bile duct, and right hepatic artery during dissection of the triangle of Calot. The identification of the danger zone is the key point of the technique and the reason why Ferzli et al. present their technique of systematic identification of Node of Calot as an important adjunct to the critical view of safety.
In this way, surgeon can avoid hepatic duct, common bile duct, and right hepatic artery during dissection.
Because the Node of Calot always "rides" the cystic artery, surgeon must have extra careful if the node presents in the inferior part of the triangle of Calot because it indicates an anatomical variation between cystic artery and cystic duct.
Laparoscopic cholecystectomy can have a negative impact in Q-o-L of patients because of potential major complications that can lead to death. Surgeons performing LC must know all possible techniques that can reduce BDI rate. Contrasting to some surgeons' idea, intraoperative cholangiography is not the solution, and there is a lack of evidence supporting its systematic use. The use of cholangiography must be individualized, ex. in case of difficult identification of anatomic structures, clinical evidence of common bile duct stones not extracted by previous ERCP. This technique can also have complications and is time consuming. Not all patients need an intraoperative cholangiography, I think.
In fact, there seems to be no ideal technique to completely avoid BDI. As we all know, critical view of safety is crucial and mandatory during LC, allowing a two structures view (cystic duct and cystic artery) going to the gallbladder after dissection of triangle of Calot and before any ligation. Using the standard approach presented by Ferzli et al I believe LC can be performed more safely. Identification of Node of Calot should be the first step of LC.
Surgeons should/must identify the Node of Calot and the danger zone before proceeding to dissection of triangle of Calot and the critical view of safety. At least this is my conviction...
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon