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There is little question that laparoscopic surgery in general surgery has had the greatest impact in the treatment of cholelithiasis and cholecystitis with over 80% of cholecystectomies being performed laparoscopically and laparoscopic cholecystectomy being one of the most common general surgical procedures performed. Although laparoscopic cholecystectomy has led to more frequent surgical treatment of gallbladder disease and a reduction in postoperative pain and hospital stay, as well as earlier return of bowel function and full activity, and decreased cost, it has not led to a reduction in the incidence of common bile duct (CBD) injuries. The most recent data cite an estimated incidence of 0.4–1.3% bile duct injuries after laparoscopic cholecystectomy compared to 0.2% after open cholecystectomy with significant patient morbidity and a high risk of litigation.1,2 It has always seemed odd that, faced with a bile duct injury, no more than 15% of surgeons refer these patients to subspecialty hepatobiliary surgeons for repair.3 The risk of bile duct injury had been thought to be greater earlier in a surgeon's experience with a 1.7% incidence of bile duct injury in the first case and a 0.17% chance of bile duct injury in the 50th case.4 However, other studies have shown that there is no reduction in risk as surgeons do more cases.2,5
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Anatomic variability is common in the biliary tree and methods to reduce the incidence of bile duct injury have included routine cholangiography, identifying the boundaries of Calot's triangle, and identifying the “critical view,”6 all appropriately emphasized by Auyang and Soper.1 However, it has been my practice to emphasize to the residents to “stay on the gallbladder, stay on the gall bladder, and stay on the gosh darn gallbladder” as the most effective way to avoid injury to either the CBD or right hepatic artery. This prevents transection of the CBD and, if adhered to as the gallbladder is dissected free of the gallbladder fossa adjacent to the porta hepatis medially, will prevent injury to a low-lying right or right posterior hepatic duct. If this is not easily accomplished due to acute cholecystitis or other abnormalities, consideration should be given to converting to an open procedure. This principle still holds true for an open cholecystectomy as well. Late conversion is often associated with bile duct injuries. Although cystic duct leaks, transection or clipping (partial or complete) of the CBD or common hepatic duct have been the most commonly described injuries; increasingly we are seeing injuries to the right hepatic duct or right posterior hepatic duct which may be difficult to characterize as they are not in communication with the common duct and may be missed on endoscopic retrograde cholangiopancreatography (ERCP).7 Only with percutaneous transhepatic cholangiography (PTC) or injection of a subhepatic drain, along with a high index of suspicion, will they be identified.
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Because most patients with suspected choledocholithiasis undergo preoperative ERCP, there are fewer laparoscopic ...