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This is a perspective on biliary diseases to complement a number of excellent chapters on biliary tract disease in this text. It focuses on areas that I believe require emphasis and areas where we are lacking information. Understandably, the latter is often controversial.

Biliary injury is still a serious problem and major injuries are most often caused by a misidentification, in which the common bile duct (CBD) is taken to be the cystic duct. Unfortunately, good updated epidemiological data are lacking, so the true incidence of biliary injury is unknown. Based on the referral data the problem still seems to be substantial.

The Rationale of the “Critical View of Safety”

The critical view of safety (CVS) technique was developed to mimic a technique of ductal identification used for open cholecystectomy.1,2 In that method the cystic duct and the cystic artery are first putatively identified by dissection in the hepatocystic triangle. Identity is then confirmed by freeing the gallbladder from the cystic plate so that the gallbladder is pedunculated on the two cystic structures only. The rationale of CVS is to reproduce the principles of this method without removing the gallbladder completely from the liver bed since this leads to undesirable twisting of the organ. To attain the CVS the triangle of Calot must be cleared of fat and fibrous tissue revealing two and only two structures entering the gallbladder and the base of the gallbladder has to be freed from the lower one-third of cystic plate so that it is apparent that the dissection is clearly onto the cystic plate. If any doubt exists more of the gallbladder should be freed off the plate. The CVS technique is not a method of dissection. It is a method of identification. The moment of identification should preferably be treated like a “time out” with the surgeon pointing out the CVS to the operative team before going on. A number of publications have now supported this method of ductal identification but level 1 evidence will never be attained since comparing methods for an event that occurs with a frequency of 0.1–0.4% would require a randomized trial with 4000 patients per arm. Cholangiography should be used liberally and preferably always when a less sure method such as the infundibular technique is used. Cholangiography is effective in reducing the incidence and extent of major injuries but is less effective in preventing injuries to aberrant ducts.

Culture of Cholecystectomy

The author's conclusion, arrived at from reading a large number of operative notes, is that biliary injury is sometimes the result of persistence in performing cholecystectomy, usually in the face of severe acute and/or chronic inflammation. Although the Cochrane group arrived at the conclusion that one could not detect an increase in the incidence of biliary injury in patients who have cholecystectomy in the presence of acute cholecystitis, the number of patients available ...

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