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The “Hidden Cystic Duct” Syndrome and the Infundibular Technique of Laparoscopic Cholecystectomy—the Danger of the False Infundibulum Steven M Strasberg, MD, FACS, FRCS(C), Christopher J Eagon, MD, Jeffrey A Drebin, MD, FACS Background: The “classical” biliary injury usually in- 2000;191:661–667. © 2000 by the American volves misidentification of the common bile duct as the College of Surgeons) cystic duct. The purpose of this study was to determine if the method of cholecystectomy, specifically the “in- Biliary injury during laparoscopic cholecystectomy fundibular technique,” might be a contributing factor in this injury. continues to be an important cause of morbidity. Injury rates are probably decreasing, but have not Study Design: Twenty-one operative notes of patients yet attained the levels that were once present in the who were referred with injury to the common bile duct era of open cholecystectomy.1-3 The “classical” bili- were examined. Notes were classified as to informative- ary injury occurs when the common bile duct is ness. Patient and operative variables potentially related injured as a consequence of the mistaken belief that to injury were searched for. it is the cystic duct, ie, it is misidentified.4 The Results: Inflammation was the main patient variable degree of severity of the injury ranges from simple associated with injury. The main operative variable was obstruction to excision of large parts of the extrahe- that in most of the injuries the cystic duct was isolated patic biliary tree and, at worst, results in the need and divided as the first step in the procedure. Often the for a very high biliary reconstruction5-7 or even liver operative note contained a statement indicating that resection or transplantation. the surgeon believed that the “cystic” duct (actually the The problem of misidentification of the com- common bile duct) was emanating from the infundib- mon bile duct as the cystic duct during laparoscopic ulum of the gallbladder and that this was the anatomic cholecystectomy is well recognized.1-3,8,9 A number rationale for identification of the cystic duct. In no case of contributing factors have been recognized, such was the triangle of Calot completely dissected before 10-11 injury. as direction of traction of the gallbladder and adhesive bands.12 Most surgeons are aware of these Conclusions: The cystic duct may be hidden in some pitfalls. Yet despite this and all that has been written patients having laparoscopic cholecystectomy, espe- about misidentification, injuries to the common cially in the presence of inflammation. This may lead bile duct are still occurring with disturbing frequen- to the deceptive appearance of a false infundibulum cy.3 In discussing the mechanism of injury with sur- that misleads the surgeon into identifying the common geons who have referred patients for reconstruction, duct as the cystic duct. Biliary injury is more likely we have been struck by the fact that highly compe- when cystic duct identification is made by relying solely on the appearance of the junction of the cystic tent, experienced, and informed surgeons have been duct with the infundibulum of the gallbladder, and this convinced that they were dissecting the cystic duct technique should be abandoned. (J Am Coll Surg when, in fact, they have been isolating a segment of the common bile duct. This has caused us to hy- No competing interests declared. pothesize that there might be a flaw in some tech- niques by which laparoscopic cholecystectomy is Received May 5, 2000; Revised July 10, 2000; Accepted July 24, 2000. performed—a flaw associated with a visual From the Section of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, Department of Surgery, Washington University, St Louis, MO. deception. Correspondence address: Steven M Strasberg, MD, FACS, FRCS(C), Box There are two well-described methods for duc- 8109, Suite 17308 Queeny Tower, 1 Barnes Hospital Plaza, St Louis, MO 63110. tal identification in laparoscopic cholecystectomy. © 2000 by the American College of Surgeons ISSN 1072-7515/00/$21.00 Published by Elsevier Science Inc. 661 PII S1072-7515(00)00717-1 662 Strasberg et al Hidden Cystic Duct Syndrome J Am Coll Surg occurred were examined. The results support the conclusion that the infundibular technique is an unreliable method of ductal identification, espe- cially when local conditions conspire to hide the true cystic duct. METHODS Forty-seven patients were referred to us for repair of major biliary injuries in the past 7 years. Twenty patients had injury to aberrant ducts or sustained an injury at open cholecystectomy and were not of interest in this analysis. Twenty-seven patients had undergone laparoscopic cholecystectomy and were found to have a classical injury. The operative note was available in 21 of these patients (78%). It could Figure 1. The “critical view of safety.” The triangle of Calot is not be obtained in the other six patients who had a dissected free of all tissue except for cystic duct and artery, and the classical injury. base of the liver bed is exposed. When this view is achieved, the two structures entering the gallbladder can only be the cystic duct Operative records were examined for operative and artery. It is not necessary to see the common bile duct. (Mod- and patient variables that might have contributed to ified from: Strasberg SM, Hertl M, Soper NJ. An analysis of the the injury. Patient variables included presence or problem of biliary injury during laparoscopic cholecystectomy. absence of acute cholecystitis, severe chronic in- J Am Coll Surg 1995;180:101–125, with permission.) flammation, wall thickening, tenseness or disten- sion of the gallbladder, stone impaction in the in- One is the “critical view of safety” technique, which 9 fundibulum, adhesions, abnormal anatomy, and we described in 1995. This method requires com- obesity. Operative variables were method of chole- plete dissection of the triangle of Calot and separa- cystectomy, particularly whether the triangle of tion of the base of the gallbladder from the liver bed. Calot was cleared before clipping cystic structures The anatomic rationale for identification of the cys- (“critical view” method), or whether the cystic duct tic structures results from the fact that there are two, was isolated and divided before complete dissection and only two, structures entering the gallbladder, of the triangle of Calot. We sought to ascertain the which is otherwise still attached only by the upper 9,13 anatomic rationale for concluding that the structure part of the liver bed (Fig. 1). The second and identified as the cystic duct was, in fact, the cystic older method has been referred to as the “infundib- duct—whether it was traced onto the gallbladder or ular” or “infundibular-cystic” technique. In this followed to the common bile duct or whether op- method the cystic duct is isolated by dissection on erative cholangiography was used for this purpose. the front and the back of the triangle of Calot and Excessive bleeding obscuring the field was another once isolated it is traced on to the gallbladder. Con- operative factor that was searched for. clusive identification, ie, the anatomic rationale for identification, occurs as a result of seeing the char- RESULTS acteristic flare, as the cystic duct widens to become the gallbladder infundibulum. Often this is referred Patient demographics and injury type to as seeing a funnel shape. The infundibular There were 18 women and 3 men, average age 37 method is the one usually found in texts describing years (range 16 to 78 years). The injuries occurred the technique of laparoscopic cholecystectomy. from 1990 to 1999; 11 of the 21 injuries occurred The purpose of this study was to look for con- recently, in the years 1997–1999. The injury types tributing factors to the “classical” injury. Particu- were E1, three patients; E2, four patients; E3, three larly, we wished to determine whether the method patients; E4, eight patients; and E5, three patients of cholecystectomy was a factor in the injury. Op- (Fig. 2). Although E5 injuries involve damage to an erative notes of procedures in which such an injury aberrant duct, misidentification of the common Vol. 191, No. 6, December 2000 Strasberg et al Hidden Cystic Duct Syndrome 663 bile duct as the cystic duct also occurs during this injury (Fig. 2), so this injury type is included in the analysis. The injury was discovered intraoperatively in 8 of the 21 patients. In the remainder the diag- nosis was made in the postoperative period ranging from 2 days to 3 weeks after operation. Of these 13 patients, 7 presented with sepsis including cholan- gitis, 5 presented with jaundice as the main symp- tom, and 1 with a bile fistula. Operative notes There was great variability in the length and detail of the operative notes. But the subject matter of all operative notes was uniform up to the point in the dissection at which the “cystic duct” was clipped and divided. All describe, in varying degrees of de- tail, the preparation of the patient, creation of the pneumoperitoneum, insertion of trocars, retraction of the gallbladder, and isolation of the cystic duct (and sometimes artery). We divided the operative notes into two categories—“informative” and “uninformative,” based on whether they contained patient or opera- tive risk factors for biliary injury and whether the surgeon provided the anatomic rationale by which he identified the cystic duct conclusively—in other words, what precautions were taken to avoid injury from misidentification. Uninformative operative notes provide almost no account of patient vari- ables. In regard to operative factors, the description of the part of the operation in which the “cystic” duct was identified and divided in these notes may be paraphrased simply as: “The cystic duct was iso- Figure 2.

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