EXPOSURE FOR LAPAROSCOPIC CHOLECYSTECTOMY DISSECTION ADVERSELY ALTERSBILIARY DUCTAL ANATOMY

Background: Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystect omy (LC), as initially described, is done with cephalad traction on th e gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury. Methods: Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a per cutaneous introducer placed anterior to the gallbladder. Exposure of C alot's triangle was maintained with cephalad traction on the gallbladd er fundus. IOC was repeated after allowing the organ to assume the ana tomic position. The cholangiograms were inspected for significant diff erences, and the angle of the cystic to the hepatic duct (CDHD) was me asured by a blinded radiologist. Results: The mean angle of the cystic to hepatic duct was 30 degrees +/- 19 degrees in the IOCs taken with cephalad traction on the gallbladder fundus vs 59 degrees +/- 22 degre es, P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts w ere seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction. Conclusions: From these data we conclude (I) extrahepatic biliary ducts may be at i ncreased risk of injury during LC because of the exposure technique an d (2) imaging bile ducts in the anatomic position may convey misleadin g information about the relative location of important structures. Opt imal exposure for dissection of Calot's triangle should utilize a seco nd clamp on the infundibulum with lateral, caudal traction.