Abstract
Background. Injury to the bile ducts is the most important complication of laparoscopic cholecystectomy
(LC), affecting approximately 2000 patients annually in the United States. Traditional
surgical teaching fails to provide adequate extrabiliary reference points. A “person
approach” of blame and shame (as distinct from a “system approach”) has evidently
been unsuccessful in controlling this problem. New strategies are needed. High-reliability
organizations such as aviation and the nuclear power industry have well-developed
system-based error prevention programs; the application to laparoscopic operations
of some principles used in these programs merits evaluation. In addition, some time-honored
teaching of steps to safeguard the bile duct needs to be re-examined. Methods. A review of the literature and of 34 cases of bile duct injury referred to the author
was carried out. Traditional surgical teaching was evaluated to identify reasons why
it has failed to prevent bile duct injury. New extrabiliary reference points were
used. Error prevention strategies derived from the aviation and maritime industries
were modified for application to LC. These principles have been applied in a prospective
study of 2000 successive LCs carried out on 1 surgical unit, including operations
by surgical trainees. Results. The literature and case review indicated that misidentification of biliary anatomy
was the major cause of bile duct injury and the injury was unrecognized by the operating
surgeon in 3 out of 4 cases, suggesting that traditional surgical teaching provides
inadequate reference points to prevent duct misidentification, that spatial disorientation
analogous to navigation errors occurs, and that systemic factors predisposing to error
are present. Several principles used in navigation were applied. “Human factors,”
educational principles derived from aviation crew resource management training, were
applied. No bile duct injuries occurred in the 2000 LC operations. Eight patients
had biliary leakage develop but all recovered without further surgical intervention.
Conclusions. Laparoscopic bile duct injury continues to occur at an unacceptable rate. New strategies
involving a system approach and using principles adopted by the aviation and maritime
industries were applied in 2000 consecutive LCs without bile duct injury. The application
in the operating room of commonly taught navigation principles, the use of extrabiliary
reference points such as Rouvière's sulcus, and the introduction of human factors
education for surgeons reduces the frequency of bile duct injury. (Surgery 2002;132:826-35.)
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Article info
Publication history
Accepted:
May 25,
2002
Footnotes
*Reprint requests: Thomas B. Hugh, FRCS, FRACS, Suite 1006, St Vincent's Clinic, 438 Victoria St, Darlinghurst NSW 2010, Australia.
Identification
Copyright
© 2002 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
