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Laparoscopic cholecystectomy is the gold standard procedure for initiation of a surgeon to the field of therapeutic endosurgery. It is an index operation for the training and evaluation of endoscopic surgeons. It is an index of endosurgeon's social prestige and social perception of endoscopic surgery as well.
Cholecystectomy, performed first by Carl Langenbuch in Europe and then by Justus Ohage in America, has been an index of innovations in surgical approaches as well. Piloted from the open era to the endoscopic era by Eric Muhe, laparoscopic cholecystectomy remains an index for the reporting of new endosurgical approaches, whether transgastric, transvaginal, or transumbilical.
Irrespective of the approach, biliary tract injuries continue to haunt the endosurgeon even after eclipse of the learning (proficiency) curve [1]. Professional, social, and ethical costs associated with biliary tract injury have raised concerns across professional bodies such as the Society of American Gastrointestinal and Endoscopic Surgeons and the American Hepato-Pancreatic-Biliary Association, leading to introspection [1].
Patient-reported outcomes, the cornerstone of any new procedure [2], necessitated further analysis of possible contributory factors. Delineation of the proper biliary anatomy in all patients, use of Strasberg’s critical view of safety, and anatomic dissection have continued to be emphasized [1]. A reduction in the potential for cognitive error by “believing the seen and visible” and not trying to visualize a formed belief is important [3]. Concepts of “systems based approach” and “readbacks” have become mandatory to the practice of safe surgery [3, 4]. This error reduction model approach has proven itself in the airline, shipping and nuclear industries.
The fact that injuries still are a problem is apparent by the advocacy of intraoperative cholangiography to avoid missing the injuries [1]. Biliary tract injuries remain an index of adverse outcomes in laparoscopic cholecystectomy. Technical considerations, including the necessity of energized dissection (ED) and the possible risk of instrument malfunction, have been accepted as necessary evils [1, 5]. Universal reliance on ED in laparoscopic surgery has blunted the distinction between dissection and hemostasis. This tantamounts to acceptance of collateral damage [6] despite the higher potential for thermal spread and heat absorbance in laparoscopic surgery even with the latest ED devices [7].
With evolution of laparoscopic skills, the distinction between anatomic dissection and non-ED hemostasis has been established. Now ED is not required in the index endoscopic surgery (i.e., laparoscopic cholecystectomy) [7]. However, delineation of biliary anatomy may be a concern in cases with severe and extensive inflammation. Hopes were raised by beautiful delineation of the biliary anatomy in difficult circumstances by autofluorescence of bile used in an animal model [8]. Three years of scientific pursuit since then, have demonstrated its application in human beings now [9].
Fluorescent intravenous cholangiography using easily available and safety proven indocyanine green is a definite leap on the road ahead for safe laparoscopic cholecystectomy. Delineation of the biliary anatomy, Strasberg’s critical view, believing the visible, a systems-based approach, practicing ‘readbacks’ in flat-hierarchy team and avoidance of ED now have company with perioperative fluorescent intravenous cholangiography to enhance the limits of preventing laparoscopic biliary tract injury. Avoidance of biliary tract injuries in laparoscopic cholecystectomy truly means marching “a posse ad esse” (From possibility to reality).
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Agarwal, B.B., Mahajan, K.C. Laparoscopic biliary tract injury prevention: zero tolerance, error free performance. Surg Endosc 24, 728–729 (2010). https://doi.org/10.1007/s00464-009-0627-8
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DOI: https://doi.org/10.1007/s00464-009-0627-8