Intraoperative CholangiographyCholecystectomy is the most commonly performed elective abdominal surgical procedure in the United States. Each year approximately 750,000 cholecystectomies are performed in the United States alone.1 For every 200 cholecystectomies performed one injury to the common bile duct occurs.2
An injury to the common bile duct is a recognized serious injury, with potentially devastating consequences for patient. Moreover, medical studies have concluded that an injury to common bile duct during a cholecystectomy triples risk of death for the patient.3 It is also generally accepted that the incidence of bile duct injury during a laparoscopic cholecystectomy (LC) is reported to be twice that of open cholecystectomy (OC).4 (Studies have concluded anywhere from 0.4% for OC and 0.7% for LC to 0.2% for OC and 0.6% for LC).
The conversation to an open procedure, however, is not always ordered even when the surgeon encounters a difficult surgical field before an injury to the common bile duct occurs.Given, therefore, the higher incident of injury to the common bile duct during a laparoscopic cholecystectomy versus the traditional open procedure and the serious complications caused to the patient as a result of a common bile duct injury, why should the benefits of an intraoperative cholangiography (see also, endoscopic retrograde cholangiopancreatography [ERCP]) not be utilized by the surgeon especially when a difficult surgical procedure is encountered laparscopically?
Of course, the use of an intraoperative cholangiography carries its own known risks, as with any invasive procedure. But those risks and the potential benefits in assisting the surgeon to correctly identify the biliary structures and thereby avoid an injury to the common bile duct outweigh the risk of not using an intraoperative cholangiography when confronted with a complex laparoscopic cholecystectomy. The failure to do in such a case is malpractice.
Since 1992, it has been the consensus that when “the surgeon cannot clearly identify the anatomy of the gallbladder and portal region, in whom bleeding obscures the operative field, or in whom other problems develop during the operation that render laparoscopic cholecystectomy unsafe,” the surgeon should convert the procedure to an open cholecystectomy. It is also recognized that this conversion “is not a complication of laparoscopic cholecystectomy and should be done promptly to protect the patient from serious operative injury. This decision to convert to open cholecystectomy should be considered sound surgical judgment.”4
The conversation to an open procedure, however, is not always ordered even when the surgeon encounters a difficult surgical field before an injury to the common bile duct occurs. It is, however, routinely ordered after the injury as a necessity. This goes to the argument as to whether an injury to the common bile duct during any cholecystectomy is always, never, or sometimes malpractice. Those that argue that it is never malpractice because injury to the common bile duct is a know risk, beg the question: does the surgeon have a free pass to injury the common bile duct in any procedure. The answer is: of course not. That argument is absurd on its face, and is a flagrant attempt by insurance lobbyists to insult the surgeon from his own mistake because of his mistake; and thereby avoid paying the injured patient the compensation deserved.5
Of course, the use of an intraoperative cholangiography carries its own known risks, as with any invasive procedure.Now, as to the use of an intraoperative cholangiography during a laparoscopic cholecystectomy, since at least 1993 studies have concluded that the use of “intraoperative cholangiography in the course of laparoscopic cholecystectomy is not only valuable to detect common bile duct stones, but also to delineate the anatomy of the biliary ducts, facilitate the dissection, avoid injuries to the biliary tract and identify other abnormalities, such as fistulas, cysts and tumors of the biliary system.”6 Yet, to this day there is still reluctance by surgeons to make use of an intraoperative cholangiography in the appropriate case.
The most common source of injury to the common bile duct during a laparoscopic cholecystectomy is misidentification of the cystic duct for the common bile duct. Making use of an intraoperative cholangiography helps to decrease the risk of this mistake by the surgeon. It has been found that the failure to use an intraoperative cholangiography during a cholecystectomy increases the risk of injury to the common bile duct by 50% to 70%.8
A 2003 JAMA article concluded that an intraoperative cholangiography may decrease the risk of common bile duct injury during a cholecystectomy by helping to avoid misidentification of the common bile duct.Where the patient suffers Mirizzi’s syndrome in which the gallbladder is inflamed and adjoined to the common bile duct or when certain anatomic variants are present, an intraoperative cholangiography may be difficult to perform and the patient may be at a higher risk for injury.9 In such a case, it should be implicit, in according with the National Institutes of Health Consensus Development Conference Statement, September 14-16, 1992, that the procedure should immediately be converted to an open procedure.
The debate among the medical community revolves around the benefit of routine use of an intraoperative cholangiography, selective use, or even no use until there is already a complication. The course that has been recommended by prudent medical professionals is for routine use until there is a more accurate prediction of which patients are more likely to sustain a common bile duct injury.10
From a legal perceptive given the current state of medical technology and known and associated increased risk of common bile duct injury during a laparoscopic procedure then an open one, it is a departure from accepted practice not to use an intraoperative cholangiography during a complex laparoscopic cholecystectomy.
It has been found that the failure to use an intraoperative cholangiography during a cholecystectomy increases the risk of injury to the common bile duct by 50% to 70%.It may be debatable whether all injuries to the common bile duct are preventable even with the use of a cholangiography. Certainly, a lot depends on the skill of the surgeon. But, at the very least, all should agree that every precaution should be taken to avoid such an injury, which should include the use of an intraoperative cholangiography in the appropriate case. Not only will this approach lessen the risk of harm to the patient – which should be every surgeon’s highest priority – but will lessen the likelihood of ligation over whether the surgeon departed from accepted practice.
For example, if the surgeon commences a laparoscopic cholecystectomy and encounters a difficult surgical field for what ever reason, then appropriately uses an intraoperative cholangiography, but still has difficulty ascertaining the anatomic structures of the biliary tree, and then converts to an open procedure, and, due to no fault in technique, there is an injury to the common bile duct, the surgeon did everything that a reasonably skilled surgeon would and should do. This presents a much stronger defense then merely saying, “I thought it was the cystic duct, I’m sorry, but hey, you know, it’s a known risk.”
Perhaps it is the former approach that should be advocated and adopted by the medico-insurance lobby. It is a more reasonable one, and, more importantly, more responsible to the patients they claim to want to help. This approach rings more true then merely asserting that a common bile duct injury can never be a result of a departure from accepted surgical practice. It certainly can and is. When the surgeon is faced with a difficult procedure due to anomalies, for example, how can it be justified that the surgeon proceeded without utilizing known and accepted tools to assist in avoiding injury to the patient. Therefore, there should be no reluctance to use an intraoperative cholangiography during a laparoscopic cholecystectomy when there is any question as to the correct identification of the biliary structures.