How to prevent bile duct injuries during laparoscopic cholecystectomy

Bile duct injuries (BDIs) are the most serious complication of laparoscopic cholecystectomy with an incidence of 0.2-1.5% in elective cases. As BDIs are associated with high morbidity, mortality and costs, this complication should be prevented through safe surgical procedure and technologies. To date, we have several techniques and tools to perform a safe laparoscopic cholecystectomy. 

The dissection should be started according to anatomical landmarks, like the Rouviere sulcus which is the most important one. Critical exposure and proper use of monopolar electrocautery are fundamental to avoid any damage of biliary structures. The critical view of safety (CVS) should be achieved whenever possible. However, in case of anatomical variation or acute inflammation, the dissection required to achieve the CVS can represent a risk itself and should be avoided. 

Perioperative imaging for definition of the biliary anatomy has been demonstrated to be associated with lower incidence of BDIs and /or higher rate of identification of the biliary structures. Among the techniques, the most important ones are intraoperative cholangiography and indocyanine green fluorescence cholangiography. 

The incidence of BDIs is higher in case of acute cholecystitis due to the process of inflammation and fibrosis. In the acute setting, it is of major importance to perform the surgical procedure within 10 days from the onset of symptoms or to adopt bail-out procedures, as subtotal cholecystectomy, when needed.