In General Surgery News (a free throwaway publication we get monthly in the mail), there's an opinion piece from one Arnold Seid, MD, a general surgeon in California who discusses his own personal "five key rules" to avoid potential bile duct injury during a laparoscopic cholecystectomy. Dr. Seid is a veteran surgeon; he's done thousands of lap choles over the years and he has been serving as an expert witness in LC malpractice cases for the past 15 years. So it's worthwhile to read his take. Here're his rules:
1) Never perform a lap chole without a skilled surgeon as your assistant. (He always books his LC cases with his partner, another board certified general surgeon.)
2) Slow Down (He claims that he never finishes a LC in less than an hour.)
3) Knowledge is power, don't be afraid to open.
4) Don't try to repair a bile duct injury. (Place a drain and refer to a specialist.)
5) Don't ignore post-operative complaints. (Pain/fevers/nausea/etc deserves a thorough evaluation to rule out bile leak or CBD injury.)
Now I'll grant him the last three rules. Opening ought not to be considered a "complication". If you're not progressing, if there's any doubt, NEVER hesitate to put the tiny tools away and open the patient. To some extent I agree with rule #4 as well. If you've injured a bile duct, best to cut your losses, place a drain and let someone with expertise correct the problem. Most of time, you only get one chance to repair a bile duct injury. And I strongly support rule #5. Anytime a patient calls me after a LC with complaints of seemingly excessive pain they get a stat HIDA scan and blood work. 99.9% of the time it's overkill but you just can't afford to miss anything.
I'm not so sure about the first two rules however. With all due respect to Dr. Seid, having two board certified general surgeons scrub into every LC seems almost absurd. The idea of course is that two sets of eyes are better than one. But that logic is self-defeating. Why not get three surgeons in there? Why not have the entire surgical staff come into the room when everything is exposed and have everyone vote on whether or not it's safe to clip and cut? An infinite number of eyes are better than two sets right? Ultimately, the attending surgeon needs to take responsibility for what he/she sees and make the correct call. It's very simple. We have to be able to trust that, given appropriate exposure and technique, that any board certified general surgeon will be able to interpet the anatomy correctly.
As for rule #2, I have a hard time understanding how one could spend 60 minutes on EVERY SINGLE laparoscopic cholecystectomy. I don't rush. I don't cut or clip anything until I'm 110% certain of what I'm looking for. I do a cholangiogram on probably 95% of my cases. Even with all that, my LC cases invariably take somewhere between 20-45 minutes. I have done LC that took over an hour (adhesions/extensive inflammation/etc) but those are the rare cases.
I love LC. If I had to do 3-4 a day for the next 20 years I would be a happy general surgeon. It's an elegant operation. I haven't done thousands, but I've done enough where it's become almost automatic. I try not to waste any moves. Every act is purposeful. Rarely is there struggling or the sort of futzing around that can occur when doing a laparoscopic colon resection. So here are my tips:
1) Never use a Veress needle. Why blindly stick a needle into your patient's belly? It's ridiculous. I do an open Hasson insertion. It's not slower. It's definitely safer. It's a no brainer.
2) Don't use cautery while doing the initial dissection. I gently tease down first the peritoneum, then the fibroadipose tissue with a Maryland dissector. Don't do it roughly. Don't rip things. Be patient. A single strand at a time if you have to. It will reveal itself to you.
3) Don't forget to do a posterior dissection. In other words, flip the infundibulum to the patient's left and open up that peritoneum and space behind and to the right of the cystic duct/infundibular interface.
4) Cholangiogram! Really no excuse not to do one. You'll feel better about the case if you make cholangiography a routine part of your technique. I didn't do many at all as a resident (attending choice) but since I've been in practice I plan to do one on every LC. It doesn't add much time. It really doesn't. And the more you do, the faster it goes. Anymore, if I don't do a cholangiogram for some reason (dye leakage, patient body habitus, etc.) I feel like you would if you went to work one day and realized at noon that your zipper had been down all day. A nice cholangiogram just makes me feel all warm and fuzzy inside.
5) I use the 10mm clips on the duct. I just don't like the 5mm clip devices. Maybe I'm using the wrong product, but I just feel that the smaller clips don't go on as well. The subxiphoid incision I make is consequently a little larger, but it's worth it to my sense of well-being.
6) Hook cautery when dissecting the gallbladder out of the liver bed. It's better than the spatula. You can actually sort of dissect with the hook, which allows you to get into the exact tissue plane, thereby minimizing bleeding/bile spillage.
7) I use a bag to retrieve the gallbladder on every case. Studies suggest that at least 20% of gallbladders (even non-inflamed ones) are colonized with bacteria. So why pull a potentially dirty, devascularized specimen out through a clean umbilical incision?
8) I'm pretty conservative when it comes to placing Jackson-Pratt drains. I leave one in for 24 hours for nasty, pus-filled gallbags or if there's a lot of bile spillage or bleeding. Also, if I'm worried about the cystic duct stump (friable, inflamed, ischemic). The drain helps me identify an early stump leak.