Key Strategies for Surgical Safety
Laparoscopic cholecystectomy is considered the gold standard in the treatment of cholelithiasis and other gallbladder pathologies. Despite its popularity and benefits, such as reduced recovery time and less postoperative pain, bile duct injuries remain a significant complication with potentially serious implications for patient health. This article explores the ten key preventive measures that surgeons should consider to minimize the risk of injuries during the procedure.
The prevention of bile duct injuries during laparoscopic cholecystectomy is a highly relevant topic in digestive surgery. The incidence of bile injuries, which ranges from 0.2% to 1.3%, underscores the need for effective preventive measures.
Preventive Measures
- Critical View of Safety (CVS): The CVS technique is fundamental for the correct identification of cystic structures before dissection. The American Society of Gastrointestinal and Endoscopic Surgeons (SAGES) strongly recommends this approach to avoid surgical errors.
- Intraoperative Cholangiography: Intraoperative cholangiography is a valuable tool for clarifying bile duct anatomy, especially in cases of uncertainty. SAGES suggests its routine use in situations of doubt.
- Laparoscopic Ultrasound: This technique can be an effective alternative to cholangiography, providing clear visualization of bile duct anatomy, particularly in complex cases.
- Meticulous Dissection and Anatomical Identification: Careful dissection of the Calot triangle and clear identification of all structures before transection are crucial to avoid inadvertent injuries.
- Proper Traction Use: Applying cephalic traction on the gallbladder fundus and lateral traction on the infundibulum helps better expose the cystic duct, facilitating visualization and dissection.
- Avoid Excessive Cautery Use: Excessive use of cautery can cause thermal injuries. It is recommended to use low-power settings to minimize this risk.
- Recognition of Hazardous Circumstances: The ability to identify and adapt the surgical technique in cases of severe inflammation or aberrant anatomy is vital for patient safety.
- Conversion to Open Surgery: In situations of anatomical difficulty or high risk of injury, conversion to open surgery should be considered as a safe option.
- Continuous Training and Education: Ongoing education for surgeons in safety techniques, such as CVS, is essential for the safe practice of laparoscopic surgery.
- Use of Alternative Techniques: In cases of difficult anatomy, techniques such as partial cholecystectomy or the “fundus-first” approach may be employed to reduce the risk of injury.
Conclusions
The systematic implementation of these measures can significantly reduce the risk of bile duct injuries during laparoscopic cholecystectomy. Continuous education and adaptation of surgical techniques to the specific circumstances of each patient are fundamental to ensuring the safety and effectiveness of the procedure. With the increasing adoption of laparoscopic cholecystectomy in Brazil, where the incidence of bile duct injuries is a growing concern, the application of these guidelines is more relevant than ever. As renowned surgeon Sir William Osler said, “Medicine is a science of uncertainty and an art of probability.”
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