Prevention of Bile Duct Injury During Cholecystectomy
Publication Date: May 1, 2020
Last Updated: March 14, 2022
Recommendations
Critical View of Safety (CVS)
In patients undergoing laparoscopic cholecystectomy, we suggest that surgeons use the critical view of safety (CVS) for anatomic identification of the cystic duct and artery. (, )
(expert opinion)
607
When the critical view of safety cannot be achieved and the biliary anatomy cannot be clearly defined by other methods (e.g. imaging) during laparoscopic cholecystectomy, we suggest that surgeons consider subtotal cholecystectomy over total cholecystectomy by the fundus-first (top down) approach. (, )
(expert opinion)
607
Video Versus Photo Documentation
No recommendation could be provided for this question due to a lack of agreement of the expert panel and concerns regarding feasibility, acceptability, and medico-legal considerations. (, )
607
Intraoperative Imaging
In patients with acute cholecystitis or a history of acute cholecystitis, we suggest the liberal use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy to mitigate the risk of bile duct injury. Surgeons with appropriate experience and training may use laparoscopic ultrasound imaging as an alternative to IOC during laparoscopic cholecystectomy. ( Conditional , Very Low )
607
In patients with uncertainty of biliary anatomy or suspicion of bile duct injury during laparoscopic cholecystectomy, we recommend that surgeons use intraoperative biliary imaging (in particular intraoperative cholangiography) to mitigate the risk of bile duct injury. ( Strong , Very Low )
607
No recommendation was made since current evidence comparing near infrared cholangiography for identification of biliary anatomy during cholecystectomy to IOC is insufficient. (, )
607
We suggest that the use of near-infrared imaging may be considered as an adjunct to white light alone for identification of biliary anatomy during cholecystectomy. ( Conditional , Very Low )
607
The GDG noted that relying on near-infrared imaging must not be a substitute for good dissection and identification technique. (, )
(expert opinion)
607
Risk Stratification
For patients with acute cholecystitis, we suggest that surgeons may use the Tokyo Guidelines 18 (TG18), American Association of Surgery for Trauma (AAST) classification, or another effective risk stratification model for grading for severity of cholecystitis and for patient management. (, )
(expert opinion)
607
During operative planning of laparoscopic cholecystectomy and intraoperative decision-making, we suggest that surgeons consider factors that potentially increase the difficulty of laparoscopic cholecystectomy such as male sex, increased age, chronic cholecystitis, obesity, liver cirrhosis, adhesions from previous abdominal surgery, emergency cholecystectomy, cystic duct stones, enlarged liver, cancer of gallbladder and/or biliary tract, anatomic variation, bilio-digestive fistula, and limited surgical experience. (, )
(expert opinion)
607
Risk Prediction Models
No recommendation was made since no risk prediction models exist that incorporate the presence or absence of gallstones as a factor that increases bile duct injury or difficulty of laparoscopic cholecystectomy. (, )
607
Timing
In patients presenting with mild acute cholecystitis (according to Tokyo Guidelines), we suggest surgeons perform laparoscopic cholecystectomy within 72 hours of symptom onset. ( Conditional , Very Low )
For patients with moderate and severe cholecystitis there is insufficient evidence to make a recommendation, particularly as it relates to the outcome of bile duct injury.
607
Technique
When marked acute local inflammation or chronic cholecystitis with biliary inflammatory fusion (BIF) of tissues/tissue contraction is encountered during laparoscopic cholecystectomy that prevent the safe identification of the cystic duct and artery, we suggest that surgeons perform subtotal cholecystectomy either laparoscopically or open depending on their skill set and comfort with the procedure. (, )
(expert opinion)
607
For patients requiring cholecystectomy, we suggest using a multi-port laparoscopic technique instead of single port/single incision technique. ( Conditional , Moderate )
607
In patients with acute calculous cholecystitis previously treated by cholecystostomy who are good surgical candidates, we suggest that interval cholecystectomy is preferred after the inflammation has subsided. For poor or borderline operative candidates, we suggest a non-surgical approach that may include percutaneous stone clearance through the tube tract or tube removal and observation if the cystic duct is patent. (, )
(expert opinion)
607
Conversion to Open Cholecystectomy
No recommendation was made since the current evidence comparing conversion versus no conversion to open cholecystectomy to limit/avoid BDI in the difficult cholecystectomy is insufficient. (, )
607
Time Out to Verify
Current evidence is insufficient to make a recommendation. However, as best practice, we suggest that during laparoscopic cholecystectomy, surgeons conduct a momentary pause for the surgeon to confirm in his/her own mind that the criteria for the critical view of safety have been attained before clipping or transecting ductal or arterial structures. (, )
(expert opinion)
607
Two Surgeons Versus One
No recommendation was made since the current evidence comparing two versus on surgeons for limiting/avoiding BDI in cholecystectomy is insufficient. (, )
607
Continued Education
We suggest as a best practice continued education of surgeons regarding the critical view of safety during laparoscopic cholecystectomy that may include coaching. ( Conditional , Very Low )
607
Training of Surgeons
No recommendation was made since the current evidence comparing simulation or video-based training versus alternative surgeon training modalities on limiting/avoiding BDI during LC is insufficient. (, )
607
Assistance
We suggest that surgeons have a low threshold for calling for help from another surgeon when practical in difficult cases or when there is uncertainty of anatomy. ( Conditional , Very Low )
607
When a bile duct injury (BDI) has occurred or is highly suspected at the time of cholecystectomy or in the post-operative period, we recommend that surgeons refer the patient promptly to a surgeon with experience in the management of BDI in an institution with a hepato-biliary disease multispecialty team. When not feasible to do so in a timely manner, prompt consultation with a surgeon experienced in the management of BDI should be considered. ( Strong , Low )
607
Recommendation Grading
Overview
Title
Prevention of Bile Duct Injury During Cholecystectomy
Authoring Organization
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
May 1, 2020
Last Updated Month/Year
April 13, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Physician, nurse, nurse practitioner, physician assistant
Scope
Prevention, Management
Diseases/Conditions (MeSH)
D017081 - Cholecystectomy, Laparoscopic, D002763 - Cholecystectomy
Keywords
Practice guideline, Cholecystectomy, Bile duct Injury, Laparoscopic cholecystectomy, gallstone
Supplemental Methodology Resources
Methodology Supplement, Methodology Supplement, Methodology Supplement, Methodology Supplement, Methodology Supplement, Methodology Supplement, Methodology Supplement