Rules of Thumb to Help Prevent Bile Duct Injuries

  • Optimize Imaging:
    • Use high-quality imaging equipment
  • Initial Steps and Objectives:
    • Before starting the dissection:
      • Use the triangle of Calot for orientation
    • Find the cystic duct starting at the triangle of Calot
    • Pull the gallbladder infundibulum laterally to open the triangle of Calot
    • Clear the medial wall of the gallbladder infundibulum
    • Make sure the cystic duct can be traced uninterrupted into the base of the gallbladder
    • Open any subtle tissue plane between the gallbladder and the presumed cystic duct:
      • The real cystic duct may be hidden in there
  • Factors that Suggest One may be dissecting the Common Duct instead of the Cystic Duct :
    • The duct when clipped is not fully encompassed by a standard M/L clip (9 mm)
    • Any duct that can be traced without interruption to course behind the duodenum is probably the common bile duct
    • Another unexpected ductal structure is present
    • A large artery is behind the duct:
      • The right hepatic artery runs posterior to the common bile duct
    • Extralymphatic and vascular structures are encountered in the dissection
    • The proximal hepatic ducts fail to opacify on operative cholangiograms

#Arrangoiz #Surgeon #Teacher

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