Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy

Abstract

Background: Correct assessment of biliary anatomy can be documented by photographs showing the "critical view of safety" (CVS) but also by intraoperative cholangiography (IOC).

Methods: Photographs of the CVS and IOC images for 63 patients were presented to three expert observers in a random and blinded fashion. The observers answered questions pertaining to whether the biliary anatomy had been conclusively documented.

Results: The CVS photographs were judged to be "conclusive" in 27%, "probable" in 35%, and "inconclusive" in 38% of the cases. The IOC images performed better and were judged to be "conclusive" in 57%, "probable" in 25%, and "inconclusive" in 18% of the cases (P < 0.001 compared with the photographs). The observers indicated that they would feel comfortable transecting the cystic duct based on the CVS photographs in 52% of the cases and based on the IOC images in 73% of the cases (P = 0.004). The interobserver agreement was moderate for both methods (kappa values, 0.4-0.5). For patients with a history of cholecystitis, both the CVS photographs and the IOC images were less frequently judged to be sufficient for transection of the cystic duct (P = 0.006 and 0.017, respectively).

Conclusion: In this series, IOC was superior to photographs of the CVS for documentation of the biliary anatomy during laparoscopic cholecystectomy. However, both methods were judged to be conclusive only for a limited proportion of patients, especially in the case of cholecystitis. This study highlights that documenting assessment of the biliary anatomy is not as straightforward as it seems and that protocols are necessary, especially if the images may be used for medicolegal purposes. Documentation of the biliary anatomy should be addressed during training courses for laparoscopic surgery.

Fig. 1

Correct documentation of the critical view of safety in three photographs. A Medial view. B Lateral view. C View with an instrument through one of the windows to enhance depth perception

Fig. 2

Documentation of the biliary anatomy by intraoperative cholangiography. A Performed correctly. The trajectory of the cystic duct is clearly visible, as well as the intrahepatic bile ducts, the common bile duct, and the duodenum. B Performed incorrectly. Although the intrahepatic ducts and the duodenum are visualized, the cystic duct is not, and it could be the common bile duct that is cannulated instead of the cystic duct