Operative Strategy for the Prevention of
Common Bile Duct Injuries during
Nadjet Azzi1, Becherki Yakoubi2* and Radia Ait Chaalal3
1Department of Surgery, Hospital University of Bab El Oued Algiers, Algeria
2Department of Neurosurgery, Hospital University of Bab El Oued Algiers, Algeria
3 Department of Radiologic, Hospital University of Bab El Oued Algiers, Algeria
Submission:May 01, 2020; Published: June 09, 2020
*Corresponding author:Becherki Yakoubi, Department of Neurosurgery, BEO University Hospital, Algiers, Algeria
How to cite this article:Nadjet A, Becherki Y, Radia Ait C. Operative Strategy for the Prevention of Common Bile Duct Injuries during Laparoscopic
Cholecystectomy. Open Access J Surg. 2020; 11(4): 555819. DOI:10.19080/OAJS.2020.11.555819.
Introduction: laparoscopic cholecystectomy appeared more attractive by its multiple advantages; aesthetic, early rising, less pain and above all a shorter stay, but this requires a learning curve compared to the technical means available in laparoscopy, like a limited two-dimensional but magnifying vision, innovative instruments represented by appropriate forceps allowing dissection. This is how the laparoscopic approach was decisive in the dissection of the elements of the Calot’s triangle, moreover several teams opted for various approaches; however, the incidence of bile injury by this route is higher than that which occurred during a laparotomy. These biliary injuries caused by laparoscopy are considered more serious than in laparotomy
Patients and Methods: This is a retrospective mono-centric study over a period extending from 2003-2017, it totals 2685 cases of cholecystectomies distributed by gender in 2243 female (83.5%) and 442 male (16.4%), and whose average age is 57 years with extremes (18 to 92 years). The same operator has produced this series for over a decade.
Conclusion: Biliary injury during laparoscopic cholecystectomy unfortunately remain a topical subject. Our experience has highlighted the effectiveness of an operative approach based on the choice of laparoscopic instruments minimizing electrocoagulation and allowing elective and a traumatic dissection biliary and vascular elements, knowing that the respect of the rules concerning a good exposure of the Calot’s triangle guarantees the safety of the surgical act as well as the prevention of biliary injuries.
Laparoscopic cholecystectomy was performed for the first time in France by Philipe Mouret in 1987, and in the USA in 1988. It became a gold standard , which allowed its worldwide development, knowing that the open approach at that time entailed its hazards and risks like the biliary injury described above; and whose management has been known for several decades [1-5]. This is how the laparoscopic approach was decisive in the dissection of the elements of the Calot’s triangle, moreover several teams opted for various approaches; however the incidence of biliary injuries by this route is 0.1- 0.9% depending on the series, they are higher than those which occurred during
a laparotomy. These biliary injuries caused by laparoscopy are
considered more serious than by the laparotomy elsewhere described by CHaudhary et al. .
The aim of our study is to demonstrate through our experience the advantage of a laparoscopic approach based essentially on the choice of instruments used in the dissection of the Calot’s triangle which has proven itself in the prevention of biliary injury during cholecystectomy laparoscopic.
This is a retrospective mono-centric study over a period extending from 2003 - 2017, it totals 2685 cases of cholecystectomies distributed by gender in 2243 female
(83.5%) and 442 male (16.4%), and whose average age is
57 years with extremes (18 to 92 years), we collected 2353
(87.6%) uncomplicated cholecystectomy and 332 (12.3%) acute
cholecystitis and chronicles. The same operator has produced this
series for over a decade.
Description of the laparoscopic cholecystectomy
i. Installation Figure 1: French position.
ii. The pneumoperitoneum is created using a de Veress
needle introduced through a supra- umbilical fascial incision and
peritoneal. (Insufflation takes place at a pressure of 10-12mmHg).
Trocars placement (Figure 2)
i. Trocar 10mm extra umbilical: camera (30-degree
ii. Trocar 5mm right hypochondrium.
iii. Trocar 5mm epigastrium (to the right of the round
ligament) liver retractor.
iv. Trocar 10mm left hypochondrium: operator
Instruments (Figure 3)
i. Window grip forceps. (5mm left hypochondrium trocar).
ii. Curved dissector forceps Figure 4. (10mm trocar right
iii. Coagulator hook. (10mm right hypochondrium trocar).
iv. Scissors. (10mm right hypochondrium trocar).
v. Vacuum and retractor. (5mm epigastric trocar).
vi. Clip holder (10mm trocar left hypochondrium).
vii. 30-degree optics. (umbilical trocar).
Exposure of the calot’s triangle after horizontal traction of
the crop towards the right makes it possible to highlight the cystic
pedicle Figure 5.
Dissection and identification of cystic pedicle (Figure 5)
Cystic pedicle horizontalized by traction; allows a rather
anterior and lateral approach of the cystic elements on their
free thimble; abutted at the level of the collar, the dissection is
carried out using an a traumatic-curved forceps; minimizing the
effect of electrocoagulation, followed by a posterior dissection
requiring the verticalization of the cystic pedicle. This elective
individualization allows the recognition of the main bile duct as
well as the vascular and biliary anatomical varieties before even
clipping or cutting, especially in case of cholecystitis (pediculitis,
fibrosis, bleeding), this step requires excellent visibility
Installation of clips (Figure 6)
The installation of the clips requires the horizontalization
of the cystic elements, allowing to have a cystic duct axis
perpendicular to the common biliary duct.
i. Set up of two clips on the cystic elements (artery and
ii. Section of cystic elements with scissors Figure 7.
Cholecystectomy is performed with the coagulator hook
Figure 8, retrograde or anterograde depending on the difficulties.
Our centre did not collect any biliary injury during or after
Rates of the bile injury ducts: 0%
In addition, complications that occurred during the surgical
procedure (Table 1) were noted; as haemorrhages in 12 patients
related to the cystic artery; at the introduction of the trocar the
latter was a source of colonic and vascular injuries in 2 patients,
difficulties were observed during acute and chronic cholecystitis
(n = 74) which represents 22% of cases, so we have collected
2 cases of biliary fistula. Other reasons for conversion such as
the discovery of a gastric stromal tumor, and for hemodynamic
instability for an undetermined reason.
We converted 99 patients to laparotomy, a rate of around 4%.
The learning curve remains the key factor contributing to the high rate of main bile duct injuries at the start of the experiment,
thus demonstrating that the risk of main bile duct injuries was
1.7% during the first cholecystectomy and 0.57% when the
surgeon had already performed 50 procedures (Graph 1). A
surgical group  showed that 90% of biliary tract wounds in a
series of 8839 laparoscopic cholecystectomies occurred mainly
before the first 30 cases in the surgeon’s experience.
The rate of biliary injury during Laparoscopic
Cholecystectomy (Table 2) remains higher than in laparotomy
(rate: 0.3 to 0.8%) they are particularly more complex, and
above all very serious, because they generally result from a
technical or instrumental fault. Indeed, the specific mechanism
of biliary injury during the laparoscopic approach is twofold:
technical (section, clipping, tearing, shredding) or thermal, the
latter generated by the coagulating hook causing burns that can
be extended and even source of biliary necrosis early or late bile
stenosis depending on the extent of the thermal attack; moreover,
monopolar electrocoagulation has been clearly implicated in this
complication, justifying its sparing use during the dissection of
Calot’s triangle [8,9].
The risk factors must be taken into account in the genesis
of the biliary injuries, they are linked above all to the patient
(advanced age; the male obesity), and to the local factors linked
to the gallbladder, besides the rate of wounds gallbladder is high
(cholecystitis: 5.5%) . (Inflammation: cholecystitis, fibrosis,
Difficulties related to excessive bleeding; anatomical varieties).
There are other factors to consider, inherent in the laparoscopic
approach; since it only offers. Only a two-dimensional vision
of the operating field, which is insufficient since it combines
the absence of palpation of the hepatic pedicle and a tangential
or lower dissection on contact with the main bile duct. The
instrumental means used in laparoscopy (hook coagulator) are
also incriminated and increases the risk of injury to the bile ducts
adding the surgeon’s inexperience with all of the other risk factors
The technical stages of cholecystectomy by laparotomy
are similar to those by laparoscopy, however the difficulties
encountered differ, they are linked to a poor adaptation of the
operator to a two-dimensional visual field, as well as to the
instrumental means whose choice remains questionable. In
addition, some authors have described the principles to prevent
biliary injuries; by paying close attention to the undeniable
contribution of the laparoscopic route during cholecystectomy,
Biliary injuries are prevented by a careful operative technique
These steps are as follows:
i. Perfect exposure of the operating field with tensioning
of the hepatic pedicle.
ii. Pulling up the liver.
iii. Pulling down the abdominal viscera through the proclive
iv. Perfect vision of the pedicle structures is essential; it
must be like that of laparotomy, for this an optic (an angle of 30
degrees) can be used [15-18].
v. The exposure of the Calot’s triangle hence the
importance of the lateral traction of the cystic infundibulum to
open the triangle (cystic channel is 90 degrees from the common
bile duct) [11-13].
vi. American technique (gallbladder is pushed upwards)
vii. anterior and posterior during the dissection of the
Calot’s triangle .
viii. Dissection begins at the level of the collar (identification
of the cystic-common bile junction).
ix. Exact identification of the cystic duct and common bile
x. Careful use of coagulation is necessary during the
dissection of the Calot’s triangle.
xi. The use of intraoperative cholangiography must be
carried out in case of doubt after complete dissection before any
ligature or section.
xii. Liberation of the gallbladder can be done completely in
contact with it.
xiii. If unidentified canal structures; conversion to
laparotomy is an attitude of safety.
Has demonstrated the advantage of a laparoscopic approach
which is essentially based on:
i. The choice of instrumentation (30° optics, fine and
ii. The exposure of the calot’s triangle which consists:
a) Retraction of the liver (exposure of the sub hepatic
b) Gripping the infundibular area of the gallbladder in the
horizontal axis for anterior and vertical vision for a double lateral
and posterior vision of the cystic pedicle.
iii. An elective atraumatic dissection minimizing
electrocoagulation of the ductal elements:
a) Dissection beginning at the level of the vesicular neck.
iv. Identification and detection of bile and vascular elements
in relation to the common bile duct and the lower hepatic border.
Apart from the anatomical varieties. We encountered
difficulties mainly related to the confinement of large stones in
addition to the inflammatory and haemorrhagic lesions caused
by acute cholecystitis, which cause a shortening of the cystic
elements adhering to the lateral edge of the common bile duct.
In these cases we have always recommended the initiation of
dissection without coagulation, using the tip of the curved forceps,
with its branches opening in the horizontal direction and parallel to the duct which allows to widen this passage to the lateral edge
of the common bile duct. This dissection gesture is atraumatic and
makes it possible to avoid the thermal effect of electrocoagulation
near the biliary duct. This dissection is valid for inflammatory
tissues and even for fibrosis.
After individualization and recognition of the cystic pedicle,
these are doubly clipped (artery). The coagulating hook usually
performs cholecystectomy, it is retrograde unless ignorance
or difficulties during individualization of the canal becomes
anterograde and allows control of the cystic pedicle. Biliary injury
during laparoscopic cholecystectomy unfortunately remain a
topical subject. Our experience has highlighted the effectiveness
of an operative approach based on the choice of laparoscopic
instruments minimizing electrocoagulation and allowing elective
and atraumatic dissection biliary and vascular canal elements,
knowing that the respect of the rules concerning a good exposure
of the calot’s triangle guarantees the safety of the surgical act as
well as the prevention of biliary injuries. Our study demonstrated
the value of surgical expertise, which comes above all from respect
for the known principles of open surgery combining it with the
A good dissection allows recognition of the biliary and vascular
elements in an atmosphere of inflammation or fibrosis and even
in the case of anatomical varieties; except that it is based on a
judicious choice of the instrumental means offered by laparoscopy.
Only for a better introduction to laparoscopic cholecystectomy,
it is necessary to consider the technical imperatives in order
to prevent iatrogenic injury of the bile ducts, and especially to
convert to laparotomy in the event of major difficulties, dead ends
or doubts. The laparoscopic approach is only one-way, it requires
expertise, and it should not contribute to the genesis of a lesion
which at the start is minimal and whose aggravation can become