What are the risk factors for bile duct injury during open or laparoscopic cholecystectomy (surgical removal of the gallbladder)?

Risk Factors for Bile Duct Injury During Cholecystectomy

The primary risk factors for bile duct injury during cholecystectomy include anatomical distortion due to inflammation, surgeon inexperience, failure to achieve critical view of safety, and specific patient factors such as male sex, age >60 years, and obesity. 1

Patient-Related Risk Factors

• Inflammatory conditions:

  • Acute cholecystitis (especially when symptoms last >48 hours)
  • Severe chronic scarring of the gallbladder
  • Scleroatrophic cholecystitis
  • Mirizzi syndrome 1

• Patient characteristics:

  • Male sex
  • Age >60 years
  • Obesity
  • Cirrhosis
  • Previous upper abdominal surgery
  • Presence of comorbidities
  • Large bile stones
  • Fever
  • Elevated serum bilirubin levels
  • Contracted gallbladder on imaging 1

Anatomical Risk Factors

• Abnormal biliary anatomy (e.g., short cystic duct or cystic duct entering the right hepatic duct)
• Excessive fat in the hepatic hilum
• Subverted anatomy due to inflammation 2
• Hepatocystic angle affected by advanced inflammation or contracting fibrosis 1

Technical and Procedural Risk Factors

• Failure to identify critical view of safety (CVS) - The most common cause of bile duct injury is failure to recognize the anatomy of the triangle of Calot 1, 2
• Use of the infundibular approach instead of CVS technique 1
• Misidentification of the cystic duct and common bile duct
• Lateral clipping of the common bile duct
• Traumatic avulsion of the cystic duct junction
• Diathermic injury during dissection of Calot's triangle 2
• Emergency laparoscopic cholecystectomy (higher risk than elective) 1

Surgeon-Related Risk Factors

• Early learning curve in laparoscopic cholecystectomy - Injuries of the common bile duct are more common during the early learning curve 1, 3
• First-year attending surgeons (75% of bile duct injuries in one study) 3
• Procedures performed during overnight shifts or weekends (75% of cases in one study) 3
• Inadequate training or experience 2

Prevention Strategies

1. Critical View of Safety (CVS) technique - When identified, the risk of iatrogenic complications is minimized 1
2. Bailout procedures when CVS cannot be achieved:
   • "Fundus-first (top-down)" approach
   • Subtotal cholecystectomy
   • Cholecystostomy 1
3. Intraoperative imaging when indicated:
   • Intraoperative cholangiography (IOC) in cases of suspected BDI or unclear anatomy
   • Indocyanine green cholangiography (ICG-C) to visualize biliary structures 1
4. Low threshold for conversion to open surgery when uncertain about anatomy 2
5. Exhaustive preoperative workup to detect at-risk conditions 1

Caveat

Despite these risk factors, it's important to note that conversion to open surgery per se does not necessarily avoid or reduce the risk of bile duct injury in difficult laparoscopic cholecystectomies. The key is proper identification of biliary anatomy regardless of approach 1.

When bile duct injury is suspected or identified, early involvement of an experienced hepatobiliary surgeon is crucial for optimal outcomes and timely return to baseline function 3.