Pitfalls of bile duct injury during laparoscopic cholecystectomy

Abstract

To avoid bile duct injury during laparoscopic cholecystectomy, we propose visualizing both the Rouvière sulcus and the right edge of the baseline of the quadrate lobe (S4) for orienting the gallbladder, then exposing the inner layer of the subserosal layer or perimuscular connective tissue (SS-inner) by bluntly dissecting the surrounding fat tissue. These steps are indispensable but inadequate because the definition of the baseline of the S4 remains ambiguous and the surface of the SS-inner resembles that of the fibromuscular layer of the extrahepatic bile duct. Although standardization ensures safety, it cannot prevent every error caused by carelessness or preconception. Thus, in addition to procedural standardization, preliminary recognition of various pitfalls can help achieve zero surgical morbidity.