Background: Bile duct injury(BDI) is a significant complication of laparoscopic cholecystectomy(LC), with higher rates compared to open cholecystectomy. This review assesses current strategies to prevent BDI and establish a safe acute cholecystectomy service for patients with acute biliary symptoms.
Method:A comprehensive review of peer-reviewed articles, guidelines, and expert opinions from PubMed, Medline and Cochrane databases.
Results:Effective strategies for safe LC include completing structured anatomy and surgical skills training and SAGE modules before accreditation. Proper patient risk assessment is crucial to prevent inexperienced surgeons from performing complex LCs. Acute cholecystitis patients should have LC within 24 hours of presentation. If cannot be performed during index admission, it should occur beyond 6 weeks. Employing technical heuristics such as the Strasberg critical view of safety(CVS), B-SAFE mnemonic, and liver segment-IV approach helps mitigate risks associated with laparoscopy’s limited tactile feedback and exposure. If CVS is unattainable, bailout procedures include subtotal cholecystectomy, cholecystostomy, procedure cessation and referral. Decision for open conversion can be guided by NASSAR scale, G10 cholecystitis severity score or CLOC score. Routine Intraoperative cholangiogram is recommended, particularly for unclear biliary anatomy, acute cholecystitis or suspicion of BDI. Tools including indocyanine green fluorescence cholangiography and intraoperative ultrasound, alongside AI systems and 3D laparoscopy, enhance biliary anatomy identification. Streamlined referrals to tertiary centres reduce risks and ensure proper BDI repair by HPB specialists. Mandatory CVS documentation ensures adherence to safety protocols.
Conclusion: This review outlines a multifaceted approach for establishing a safe and efficient cholecystectomy service to reduce BDI and improve patient outcomes.