Surgical Management of Bile Duct Injury

Abstract

As the main cause of BDI is due to misidentification of the CBD/CHD being the cystic duct, the goal of dissection is a conclusive identification of the cystic duct. A few strategies have been proposed for this: (1) Dissection of the main bile ducts so that the uniting point of the CBD and cystic duct is identified; (2) The infundibular technique. (3); The critical view of safety technique and (4) Intraoperative cholangiography. (1)  Laparoscopic dissection of the main bile ducts in order to identify the junction of the CBD and the cystic duct has been a method for reliable identification of the cystic duct prior to division. However, this method should not be encouraged as it is potentially very dangerous and the risk of damage to the CHD/CBD during dissection is increased. (2)   In the infundibular technique, the cystic duct is isolated and followed into the gallbladder by dissecting the front and back of the triangle of Calot. When the cystic duct gradually becomes the gallbladder infundibulum, it is taken as evidence of identification and the structure may be divided. Although the infundibular technique have been commonly used and taught, it has disadvantages. The cystic duct may be hidden, especially in cases of inflammation and suboptimal lateral traction of Hartmann’s pouch. This may lead to a false infundibulum with subsequent misinterpretation of the CBD as the cystic duct.