Laparoscopic Cholecystectomy with CBD and R Hepatic Artery injury

There has likely been a medical error here. Despite obtaining the critical view of safety , the surgeon describes a large size of the duct that had to be taken with a stapler and the moment that saw the "accessory duct", they. should have proceeded to perform an intra-operative cholangiogram to comfirm what they were looking at.

Given the location of the injury, Common bile duct and common hepatic duct, the surgeon must have been lower than they should have been, thus resulting in the injury.

Even though the surgeon describes triangle of safety within operative report, there was clearly an injury to the hepatic duct and artery at the index operation. I would need to see a detailed review of the surgeon’s operative report to see if there were any other factors present intraoperatively that would have accounted for altered anatomy and thus made the dissection more difficult. Either way, this injury is only secondary to an intraoperative error in judgment.

This injury could only have been caused by intraoperative decision making and incorrect identification of anatomical structures related to cholecystectomy.

Complications in laparoscopic cholecystectomy are often related to the fact that the surgeon's perception of the anatomy was incorrect. It is often difficult to reconstruct what the surgeon thought they saw from the operative notes simply because these cases are usually fairly standardized and similar, and therefore the op notes use the same language. However, in this case there are a few clues that things were out of the ordinary: a large "cystic duct" requiring stapling & two cystic arteries. - In this case the injury occurred where the surgeon thought they were dividing the cystic duct when it seems they in fact divided the common hepatic duct at the confluence of the right and left hepatic ducts. This is a high injury. "Because of the size of the cystic duct, the duct was divided with a 45 mm stapler." The cystic duct may be exceptionally large due to stones (choledocholithiasis). Or the stapler may be used to divide the infundibulum of the gallbladder. However, a surgeon should be suspicious whenever they encounter such a large "duct" because it may instead be the common bile duct, or, as in this case, the confluence of right and left hepatic ducts forming the common hepatic duct. If I have to use a stapler during a lap chole, I will call another surgeon into the room to assess the anatomy, to make sure what I _think_ I'm seeing is actually what the anatomy is. -Regarding the arterial injury, it is more difficult for me to figure out exactly how this injury occurred although the gap in the artery makes me think that the "cystic artery and accessory cystic artery" may have in fact been a tortuous right hepatic artery that the surgeon took in two places. The challenge in these sorts of injuries is that the surgeon doesn't know what they don't know -- it is a perceptual problem. There is a wealth of literature on the heuristics associated with iatrogenic injuries in lap chole. A lot of it comes down to surgical judgment, knowing when things are out of the ordinary, and knowing when to adopt another approach to avoid causing an injury. In this case, it seems that the surgeon explained away the deviations from a typical lap chole (an accessory artery, a duct requiring stapling) rather than pursuing other maneuvers to mitigate the chance of injury.

If there is confusion about the anatomy, a surgeon has several options to try to stay out of trouble. As stated above, it is helpful to have a colleague come into the room to ask their opinion. The surgeon has the option of performing the cholecystectomy from a "top down" approach (taking the fundus off the liver) and working towards the ductal structures before dividing them. This mimics an open cholecystectomy. While taking the fundus off the liver can be technically challenging, once it is dissected free, it helps with manipulation and retraction of the gallbladder and cystic duct. Things can be retracted to the right, putting the cystic duct on stretch, and really separating it from the common duct. Having done this, a surgeon could divide the infundibulum of the gallbladder if there was concern over the anatomy. The other maneuver which can be helpful is after defining a critical view of safety (a view of the liver between the cystic duct and artery), to continue to dissect the gallbladder to the right of the artery, working towards the fundus. Separating the gallbladder from the liver bed from the midpoint helps identify a frequent posterior arterial branch that may enter the back wall of the gallbladder or a biliary duct . In this particular case, the "critical view" is stated, but this is such standardized language it is hard to determine what the surgeon saw. There is always the option of performing a subtotal cholecystectomy or converting to an open procedure, but in this case the difficulty is that the surgeon did not appear to know there was a problem. There is also the possibility of shooting a cholangiogram to further define the anatomy. What is clear is that what the surgeon thought they saw was incorrect: they divided the common hepatic duct instead of the cystic duct. They divided the right hepatic artery instead of the cystic artery. Those maneuvers caused the patient's injury.

This is a iatrogenic combined CBD and right hepatic artery injury. The most likely scenario is that the surgeon thought intraoperatively that they obtained the critical view of safety, but they were working too proximally with no situational awareness, resulting in dissecting the CBD and right hepatic artery mistaking them for the cystic artery and duct, as they did not clearly dissect all scars and see the full gallbladder wall and infundibulum being free.

There was lack of situational awareness of what level the surgeon was working on, resulting in error in identification of the structures appropriately. While there might be risk factors that made this procedure difficult, when one is in doubt, an intraoperative cholangiogram, conversion to open surgery or subtotal cholecystectomy are the safe options.

This patient had a bile duct injury in a case in which the bile ducts were abberant. There should have been a high index of suspicion and this could have been prevented by a cholangiogram or by opening the patient to identify the anatomy more clearly.

This patient should have been considered for a cholangiogram.

Interesting case. There is literature that describes accessory ducts, but I have never seen one. It is clear that structures were misidentified during surgery. When one describes that a critical view was obtained, that implies that there are 2 and only 2 structures entering the gall bladder. Given that there was an accessory duct identified, it seems that there may have been at least 3 structures present (cystic duct, accessory duct and cystic artery). It was noted later that there was disruption of the common hepatic duct and the hepatic artery. An explanation could be that the hepatic artery was tethered to the posterior side of the gall bladder. There was no cholangiogram, which is essential in these cases where there must have been some concern about the anatomy given that 1. there was an accessory duct and 2. the cystic duct was so wide, it needed to be stapled.

No cholangiogram was done prior to dividing the structures. A cholangiogram would have shown the anatomy and avoided common hepatic duct injury