The SAGES Manual of Biliary Surgery

Although benign biliary disease is an area in which many surgeons have experience, there are many nuances to providing the highest quality of surgical care.  The biliary anatomy is unique but presents with anatomical variances and can be distorted by benign pathology.  Biliary surgery has been one of the areas where minimally invasive techniques were first applied in the late 1980s.  However, surgical technique has continued to evolve due to acquisition of advanced minimal surgical skills and improvement in surgical technology.  The expertise, sage, and knowledge of the members of the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) have prioritized the creation of this manual on modern biliary surgery.
This manual will provide the standard for the current state of biliary surgery in the 21st century. The SAGES Manual of Biliary Surgery will align with the new SAGES University Masters program. The Manual supplements the Masters Program Biliary Surgery Pathway. Its goal is to help the surgeon progress from the competent to the proficient and finally to the mastery level.  
Both for the surgical trainee and senior surgeon, this guidebook will also give insight into modern evaluation and management.  The highlights will emphasize what is both feasible and safe from a minimally invasive approach in biliary surgery. The concept of Safe Cholecystectomy will be defined and expounded on in detail.  The difficult cholecystectomy will be given ample coverage to include management of intraoperative bile duct injury, indications and techniques of subtotal cholecystectomy, and special attention to intraoperative diagnostic imaging that serve as adjuncts, including cholangiograpy, ultrasound, as well as indocyanine green biliary fluorescence.  We will review the updated international Tokyo guidelines for acute cholecystitis.  Furthermore, the evolution of treatment ofcholedocohlithiasis has evolved the most in recent years, and thus requires an extensive discussion of the non-operative and operative management of bile duct stones.
This text will serve as an important contribution to the medical literature sponsored by SAGES, an international leading authority in gastrointestinal surgery with a keen interest in safe and proficient biliary surgery.  Leaders in the field of biliary surgery will impart their insight and considerable experience in the chapters planned for this manual.  The intent for this manual is to be the cited resource for high quality and applicable knowledge for the treatment of benign biliary disease.

• Language: English
• Publisher: Springer
• Release date: Nov 5, 2019
• ISBN: 9783030132767

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© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

H. J. Asbun et al. (eds.)The SAGES Manual of Biliary Surgeryhttps://doi.org/10.1007/978-3-030-13276-7_1

1. Introduction to Biliary Manual

Dimitrios Stefanidis¹  

(1)

Department of General Surgery, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA

Dimitrios Stefanidis

Email: [e-mail]

Keywords

Laparoscopic cholecystectomyBile duct injuryManualSafe practices

Since its introduction approximately 30 years ago, laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease due to its low morbidity and quick patient recovery [1]. Despite this, up to 8% of patients undergoing LC develop a complication, a rate that has not changed significantly in the past 30 years [2]. Importantly, an increase in the bile duct injury rate has been observed in patients undergoing LC compared to the era of open cholecystectomy [3]. At the present time, biliary complications after laparoscopic cholecystectomy occur in approximately 1 in 100 patients, while 2–4 out of 1000 patients experience a major biliary injury that requires biliary reconstruction [2]. Considering that approximately 90% of the 1,000,000 cholecystectomies each year are performed laparoscopically in the USA, this rate translates into approximately 3000 or more major biliary injuries in the USA annually. Patients sustaining bile duct injuries require numerous re-interventions and hospitalizations, suffer a diminished quality of life, and have an up to 8.8% increased risk of mortality [4, 5]. These injuries are the most common reason for medicolegal litigation against general surgeons and place a significant economic burden on our healthcare system with an estimated annual cost of more than 1 billion dollars [6, 7].

Given the frequency of this operation and a rate of bile duct injury that has not decreased despite accumulating experience with laparoscopy over time, improving the safety of laparoscopic cholecystectomy is an important priority in surgery. To address this issue and bring it to the attention of the surgical community, the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) formed the Safe Cholecystectomy Task Force in 2014 with the mission of enhancing a universal culture of safety in LC in order to reduce biliary injuries. The group has created numerous educational materials and initiated several projects aiming to improve the safety of the laparoscopic cholecystectomy (https://​www.​sages.​org/​safe-cholecystectomy-program) [8]. More recently, with the introduction of the SAGES Masters program that aims to address existing needs of practicing surgeons for lifelong learning after training completion by providing them with the tools to achieve maintenance of certification, a biliary pathway has been created [9]. This pathway aims to educate surgeons in biliary tract surgery by offering curricula and educational material addressing three levels of performance (competency, proficiency, and mastery). Each level incorporates an anchoring procedure that is meant for training and assessment of surgeons.

The biliary manual you have in your hands provides you with an excellent resource for essential knowledge relevant to the care of patients with gallbladder disease. It is organized according to the levels of the SAGES Masters biliary pathway and addresses in-depth laparoscopic cholecystectomy and other related procedures all general surgeons should be familiar with when caring for this patient population.

In Sect. 1, at the competency level of the Masters program, the surgical anatomy of the biliary tree and the principles and technique of safe cholecystectomy are described. Further, selection of appropriate preoperative imaging, patient optimization approaches for elective procedures, and optimal timing of cholecystectomy for acute cholecystitis, including use of cholecystostomy tubes, are addressed.

At the proficiency level, the technique, advantages, and disadvantages of intraoperative biliary imaging (including cholangiogram, ultrasound, and ICG) are discussed, while at the mastery level, the management of common bile duct stones is described (including endoscopic and surgical approaches).

In Sect. 2, the management of bile duct injuries is addressed, and a description of the indications and technique of advanced biliary procedures is provided.

We are confident that this biliary manual, written by experts in the field, will provide you with the requisite knowledge to offer excellent care to your patients with gallbladder disease and assist you in the development of mastery with biliary tract procedures.

References

1.

Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy: the new gold standard. Arch Surg. 1992;127(8):917–23.Crossref

2.

Pucher PH, Brunt LM, Davies N, the SAGES Safe Cholecystectomy Task Force, et al. Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis. Surg Endosc. 2018;32(5):2175–83.Crossref

3.

The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324(16):1073–8.

4.

Törnqvist B, Strömberg C, Persson G, Nilsson M. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ. 2012;345:e6457.Crossref

5.

Zong ZV, Pitt HA, Strasberg SM, et al. Diminished survival in patients with bile leaks and ductal injuries: management strategy influences survival. J Am Coll Surg. 2018;226(4):568–576.e1.Crossref

6.

Kern K. Malpractice litigation involving laparoscopic cholecystectomy: cost, causes, consequences. Arch Surg. 1997;132:392–8.Crossref

7.

MacLean TR. Monetary lessons form litigation involving laparoscopic cholecystectomy. Am Surg. 2005;7:606–12.

8.

The SAGES Safe Cholecystectomy Program. https://​www.​sages.​org/​safe-cholecystectomy-program/​. 2015.

9.

Jones DB, Stefanidis D, Korndorffer JR Jr, Dimick JB, Jacob BP, Schultz L, Scott DJ. SAGES University MASTERS program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017;31(8):3061–71.Crossref

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

H. J. Asbun et al. (eds.)The SAGES Manual of Biliary Surgeryhttps://doi.org/10.1007/978-3-030-13276-7_2

2. Biliary Anatomy

Daniel J. Deziel¹   and Benjamin R. Veenstra¹  

(1)

Department of Surgery, Rush University Medical Center, Chicago, IL, USA

Daniel J. Deziel (Corresponding author)

Email: [e-mail]

Benjamin R. Veenstra

Email: [e-mail]

Keywords

AnatomyCommon bile duct (CBD)CBD injuryCystic ductCystic arteryCritical view of safety

Introduction

Cholecystectomy is one of the most frequently performed operations by general surgeons. Correct identification of the anatomy is requisite to its safe performance. Variations in biliary anatomy are common, both natively and as the result of pathologic conditions. A detailed understanding of hepatobiliary anatomy has been derived from classic studies based on cadaver dissection, corrosion casting, and direct cholangiography, as well as from contemporary imaging studies using 3D computed tomography (CT) and magnetic resonance (MR) reconstructions [1–12]. This chapter will highlight some of the variations in bile duct and vascular anatomy that are regularly encountered during cholecystectomy and that have practical significance for the avoidance of bile duct and vascular injury.

Terminology

In order for anatomic concepts to be properly understood and communicated, the terminology must be correct, consistent, and standard. The lexicon of hepatobiliary anatomy has historically been confused by descriptions that use different nomenclatures and imprecise eponyms. Therefore, a few remarks on the terms used in this chapter are relevant to avoid misunderstanding.

The hepatocystic triangle is the roughly triangular area bounded by the cystic duct and gallbladder, the common hepatic duct, and the edge of the liver (Fig. 2.1). This is a critical area where right hepatic ducts and the right hepatic artery can be located. This is a region often obscured by the effects of acute or chronic inflammation. This is the high-priced real estate where bile duct and vascular injuries are prone to occur. This is the area that must be cleared for anatomic identification by the critical view of safety. The size and shape of the triangle will change during the stages of dissection and with the direction of retraction. The hepatocystic triangle is not synonymous with the triangle of Calot.

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Figure 2.1

The hepatocystic triangle and critical view of safety

The triangle of Calot is a triangle bounded by the cystic duct, the common hepatic duct, and the cystic artery. It was described by Jean-Francois Calot in his 1890 doctoral thesis as an area of concern during the early era of cholecystectomy. Calot’s’ triangle has become ensconced in the surgical vernacular. However, the term is not anatomically precise as it is commonly used. Moreover, the triangle is not consistently present, since it is defined by the location of the cystic artery which can be entirely outside of this region. Hepatocystic triangle is the preferred terminology for this important anatomic area.

The critical view of safety is a method for identification of the cystic duct during cholecystectomy. It is not the only method for identification, but it is the method felt to be less subject to error than others [13]. The critical view of safety is defined by three criteria: (1) the hepatocystic triangle is cleared of connective tissue, (2) the gallbladder is dissected off of the liver demonstrating an ample portion of the cystic plate, and (3) two structures, the cystic duct and cystic artery, are seen to join the gallbladder (Fig. 2.1). The critical view cannot always be obtained, either because of natural anatomic differences or as the consequence inflammation. In these situations, the surgeon must have safe alternatives for correct identification of the cystic duct as are discussed in other chapters.

Extrahepatic bile ducts that are arranged differently from the most typical configuration are often referred to as accessory, anomalous, or aberrant ducts. Although alliterative, such terminology is generally incorrect. An accessory duct implies true embryologic duplication of drainage from the same hepatic area; such ducts are rare, if even existent. Michels noted that every duct drains a definite segmental area of the liver [6]. Use of the terms anomalous or aberrant suggests that variations are unusual, unexpected, not easily classified, or divergent from the natural type [14]. It is incorrect to apply these terms to many bile duct variations, which, in fact, are natural and well recognized and present with sufficient frequency that they should be anticipated by the watchful surgeon. Hence, variant duct is the preferred terminology.

The anatomic divisions of the liver have been conceptualized differently over time, and the terminology assigned by different anatomists has created confusion. We will use the nomenclature of the Brisbane 2000 system that is based on the intrahepatic distribution of the bile duct and hepatic artery [15]. This divides the liver into two sides, then into four sections, and then into eight segments. The corresponding ducts from the second and third level divisions are referred to as sectional ducts and segmental ducts . The anatomic divisions of the right liver are the same in the Brisbane and Couinaud systems; the only difference is that Couinaud termed the secondary divisions sectors/sectorial ducts instead of sections [5]. For the left liver, the two systems differ both in anatomic concept and terminology, but this is not applicable to our considerations for cholecystectomy. A description of the anatomical and historical basis of these differences is beyond the scope of this chapter, but an informed discussion can be found in references by Strasberg [16] and Bismuth [17].

General Landmarks for Anatomic Orientation

During laparoscopic operations, it is possible to develop tunnel vision, to be so specifically focused on such a narrow field that the wider anatomic perspective is lost. Prior to commencing dissection for cholecystectomy and as the case proceeds, it is therefore useful to pause and to note the location of certain adjacent anatomic structures. Appreciation of these landmarks can aid proper orientation and prevent straying off course into danger zones (Fig. 2.2).

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Figure 2.2

Anatomic landmarks for orientation. Note the location of the falciform ligament (a), of Rouviere’s sulcus (b), and of the duodenum (c) and the apperance of the epicholedochal plexes of vessels on the common bile duct (d)

The falciform ligament is between hepatic segments 3 and 4. The common hepatic duct (CHD) is near the midplane of the liver between segments 4 and 5. If dissection is too close to the plane of the falciform ligament, it is on the wrong side of the extrahepatic ducts.

Rouviere’s sulcus ¹ is a fissure in the liver that usually contains portions of the right portal pedicle. It is located underneath, or dorsal, to the gallbladder and anterior to hepatic segment one. It can be recognized in 75–80% of cases [18]. The sulcus demarcates the ventral-dorsal (anterior-posterior) plane of the common bile duct. Dissection must be ventral (anterior) to the sulcus to avoid injury to the bile duct or to vascular structures that are located within the sulcus.

While retracting the gallbladder, the location of the duodenum should be noted in relation to any ductal structure identified. A duct that courses directly behind the duodenum is the common bile duct (CBD), not the cystic duct.

The blood supply to the supraduodenal segment of the CBD is primarily axial and is based on a plexus of vessels that is anchored by marginal anastomotic arteries, referred to as the 3 o’clock and 9 o’clock vessels. These anastomotic vessels run between the retroduodenal artery (a branch of the gastroduodenal artery) and the RHA. The epicholedochal plexus produces a characteristic vascular pattern on the CBD that is useful to visually distinguish it from the cystic duct.

Anatomy of the Right Hepatic Ducts

In the most common arrangement, the right anterior (RA) sectional hepatic duct (from segments 5 and 8) and the right posterior (RP) sectional hepatic duct (from segments 6 and 7) unite to form the right hepatic duct (RHD), which joins the left hepatic duct to form the common hepatic duct (CHD) (Fig. 2.3). This typical anatomy occurs in 57–72% of individuals [3, 5, 8]. The corollary is that approximately one-third to one-half of individuals will have variations in the anatomy of the extrahepatic ducts. Substantial portions of these variations involve right hepatic ducts located near the field of cholecystectomy.

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Figure 2.3

Intraoperative cholangiogram demonstrating what is termed typical anatomy of the bile ducts

The most frequent and important variation in the right hepatic ducts occurs when the RA and RP ducts do not join to form a common RHD. Instead, each sectional duct has a separate junction with the CHD or the left hepatic duct. Some version of this occurs in 15–30% of people [1, 3, 5, 8]. Segmental ducts, usually from segments 5 or 6, can also drain into the CHD separately from other segmental ducts.

The junction of a separate right hepatic duct with the other extrahepatic ducts can be at a variable distance along the vertical hepatoduodenal axis. A separate RP duct tends to join the CHD further down from the hepatic hilum than a separate RA duct. Thus, the mean distance between the insertions of the cystic duct and a separate RP duct is shorter than the mean distance between the cystic duct and a separate RA duct [8]. Such anatomy brings the RP duct in close proximity to the gallbladder and the cystic duct (Fig. 2.4). Furthermore, in 1 out of 50 cholecystectomies, or 2% of individuals, the cystic duct joins a separate right sectional duct (or occasionally even the main right hepatic duct) rather than the CHD [5, 8, 9] (Fig. 2.5). These right duct variants court injury if not recognized.

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Figure 2.4

Intraoperative cholangiogram demonstrating separate junctions of the right anterior and right posterior sectional ducts with the common hepatic duct. Note the junction of the cystic duct near the separate right posterior sectional duct

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Figure 2.5

Intraoperative cholangiogram demonstrating the cystic duct joining a separate right sectional hepatic duct

A subvesical duct is another structure that is pertinent to understand for safe cholecystectomy. These are ducts located superficially in the gallbladder bed, just under Glisson’s tunic. Although they can originate from different liver areas, they most frequently represent segmental ducts from segment 5, and they most frequently drain into the RA sectional duct, RHD, or CHD [3, 20] (Fig. 2.6). Subvesical ducts are considered to be the most common source of postoperative bile leakage from the liver bed. This is best avoided by keeping the plane of dissection outside of the liver when possible.

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Figure 2.6

Intraoperative cholangiogram demonstrating a subvesical duct that joins the right anterior sectional hepatic duct

Subvesical ducts have been observed in about one-third of human specimens [3, 20, 21]. Healey and Shroy made the germinal observations that, unlike other bile ducts, subvesical ducts were not accompanied by a branch of the portal vein, and, in no instance, did they drain into the gallbladder [3]. True hepatocystic ducts, between the liver and gallbladder, have been described, but they are rare, certainly much more so than subvesical ducts. It is a misnomer to refer to either subvesical ducts or hepatocystic ducts as the eponymic ducts of Luschka. German anatomist Hubert von Luschka, in 1863, described two microscopic tubular structures in the gallbladder wall that were present on both the peritoneal and liver surfaces of the gallbladder. These are best understood today to have represented intramural glands and lymphatics [19].

Anatomy of the Cystic Duct

The cystic duct usually joins the CHD. The location of the junction can be anywhere from the hepatic hilum to the preampullary area: 80% are supraduodenal and 20% are retroduodenal or retropancreatic [2, 20]. The course of the cystic duct relative to the CHD and the pattern of union are variable. In the textbook configuration, the cystic duct has an angular entry at the right lateral aspect of the CHD; classic dissection studies noted this in 75% of specimens [2, 20, 21]. About 20% of cystic ducts course parallel to the CHD, sharing a common sheath of connective tissue. The length of a parallel course can be short (< 5 cm) in 11–15% or long (>5 cm) in 4–6% [2]. The parallel formation has long been recognized as a risk factor for bile duct injury. Five to 10% of cystic ducts take a spiral course and cross either ventral or dorsal to the CHD with a medial, posterior, or anterior confluence [2, 9, 20, 21] (Fig. 2.7). A study by intraoperative cholangiography found that the frequency of cystic duct patterns often differed from what is commonly appreciated and included a spiral course in 35%, a long parallel course in 7%, a posterior union with the CHD in 41%, and a direct lateral union in only 17% [7].

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Figure 2.7

Intraoperative cholangiograms demonstrating cystic ducts that are parallel to the common hepatic duct: (a) short and (b) long with spiral course

Two alterations in cystic duct anatomy are particularly important as risk factors for bile duct injury. The first is when the cystic duct is fused to the CHD. This can be present natively, as mentioned above, but commonly results from inflammatory fusion of the CHD with the cystic duct and neck of the gallbladder [22]. A second high-risk situation is when the cystic duct is short, which is also usually due to inflammatory contraction (Fig. 2.8). The cystic duct has sometimes been described as absent. However, this appearance is almost certainly the result of an acquired inflammatory condition. Congenital absence of the cystic duct has not been documented in compiled series of anatomic dissections [20].

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Figure 2.8

A wide, so-called short, cystic duct resulting from inflammatory contraction

Anatomy of the Cystic Artery

The cystic artery (CA) is a single vessel 75% of the time. It usually has two branches: a superficial or inferior branch on the peritoneal surface of the gallbladder and a deep or superior branch on the hepatic side. The CA can divide on the gallbladder wall or at a variable distance away from it. When the division is near the source vessel, the branches may appear to be two separate arteries in the hepatocystic triangle (Fig. 2.9). The CA originates from the right hepatic artery (RHA) 70% of the time. The location of the RHA is dorsal (posterior) to the CHD 85% of the time.

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Figure 2.9

Dorsal view of the cystic artery dividing into its deep (lower branch in photo) and superficial (upper branch in photo) branches early in the hepatocystic triangle

When the CA comes