There are no data available on the preferred operative technique to reduce the risk of bile duct injury during laparoscopic cholecystectomy in the UK. The present survey assessed the use of IOC amongst specialist upper gastrointestinal (AUGIS) surgeons who undertake laparoscopic cholecystectomy on a regular basis. There was no consensus on the use of IOC, or the practice of routine IOC (only 24%) in this group of surgeons. However, most specialist surgeons (82%) widely dissect Calot's triangle to obtain a critical view of safety prior to clipping and dividing the cystic duct and artery. This technique was first described and widely advocated by Professor Steven Strasberg, of St Louis, Missouri, USA7
and is gaining wide-spread acceptance as a safe alternative to IOC in minimising the intra-operative risk of inadvertent bile duct injury.
The practice of IOC1
has increased with the introduction of laparoscopic cholecystectomy and the associated increase in CBD injuries that occurred in the early 1990s. However, the routine use of IOC to reduce the risk of CBD injury3
is at the discretion of the operating surgeon, and several authors rather recommend the selective use of IOC based on pre-operative criteria to detect occult bile duct stones.9,10
Several studies have evaluated the use of IOC in preventing CBD injury and have concluded that both routine and selective IOC are acceptable policies for reducing the risk of CBD injury.11–13
However, many studies are underpowered and, therefore, offer limited evidence on the efficacy of IOC in reducing the rate of CBD injury. This was addressed in 2002 by a meta-analysis of 40 case-series that included 327,523 laparoscopic cholecystectomies, and calculated that routine use of IOC halved the rate of CBD injury.14
A more recent comprehensive review on the use of IOC concluded that routine IOC does appear to decrease bile duct injury and that wide-spread use of routine IOC would improve patient safety.3
The present survey noted that the practice of routine IOC is relatively low amongst OG and HPB surgeons in the UK, with only 24% recommending IOC as a routine practice.
The ‘critical view of safety’ advocated by Strasberg is generally accepted as a safe method to obtain an overview of the key anatomical structures that should be clearly identified before clipping and transecting the cystic duct.7
Recent studies have shown this technique to be effective in minimising bile duct injury.15,16
Interestingly, a recent Dutch survey reported that the concept of a critical view of safety was not wide-spread in The Netherlands, but has now been included in the Best Practice for Laparoscopic Cholecystectomy
guidance document published by the Dutch Society of Surgery.8
There are no similar technical guidelines in the UK but, in this study, most surgeons (83 %) stated that they routinely dissect Calot's triangle to provide a critical view of safety, to minimise the risk of bile duct injury during cholecystectomy.
The incidence of CBD stones in patients undergoing cholecystectomy is around 10–18%,17
and non-invasive modalities are increasingly used to investigate suspected cholelidochothiasis.18
MRCP is increasingly used to identify patients who require ERCP prior to laparoscopic cholecystectomy. As a consequence, there is now little role for ERCP as a first-line pre-operative assessment, and this is reflected in this study where only 2% of surgeons recommend ERCP for assessment of a dilated CBD on pre-operative ultrasound.
When bile duct stones are identified on IOC, the management may be surgical or endoscopic depending on local expertise. A recent Cochrane review compared open CBD exploration with pre-operative or postoperative ERCP and noted a higher clearance rate, a significantly lower mortality rate, and a trend towards decreased morbidity in patients who underwent a surgical intervention.17
The Cochrane review of laparoscopic bile duct exploration versus either pre-operative or postoperative ERCP evaluated a relatively small number of patients from four clinical trials and demonstrated less convincing results.17
A further meta-analysis found no difference in successful duct clearance, morbidity or mortality between endoscopic and surgical management, whether performed by open or laparoscopic technique.18
From these studies, it can be concluded that, for most patients, a single surgical procedure with bile duct exploration is as effective as pre-operative or postoperative ERCP, and reduces the overall hospital stay. Most surgeons (61%) in this study recommend surgical exploration of the CBD as definitive management of bile duct stones noted on IOC, where the use of an open or laparoscopic approach is dictated by local expertise.19
Interestingly, the present survey showed that surgeons practicing in university hospitals are more likely to perform a laparoscopic CBD exploration compared to surgeons practicing in district general hospitals, who are more likely to recommend postoperative ERCP.
The practice of early cholecystectomy for acute cholecystitis is quite variable, with 55% of Australian surgeons advising early laparoscopic cholecystectomy on the same admission,20
and 42% of Japanese surgeons also performing index admission cholecystectomy.21
In contrast, recent data (2008) from England reported that only 15% of patients undergo laparoscopic cholecystectomy for acute gallbladder disease in the same admission,22
which is similar to that reported in 2004 when two postal questionnaire surveys in Britain revealed that less than 20% of surgeons carried out a laparoscopic cholecystectomy following an emergency admission.23,24
. In contrast to these previously published UK statistics, it is interesting to note in this survey that 88% of AUGIS surgeons now recommend early laparoscopic cholecystectomy on the same admission for acute gall bladder disease. This may reflect the specialist interest of the AUGIS surgeons in this survey, but may also suggest there is a shift toward early surgery for patients that present with acute gallbladder pathology compared to previous surveys.