Avoidance of biliary injury during laparoscopic cholecystectomy.

Biliary injury during laparoscopic cholecystectomy is still a serious problem. Injury occurs as a result of technical errors or misidentification of ducts. Inexperience, inflammation, and aberrant anatomy are key risk factors. The most serious technical problem is cautery-induced injury. This problem may be avoided by use of cautery under very low power settings in the triangle of Calot. Misidentification injuries occur when the surgeon mistakes the common bile duct or an aberrant right hepatic duct for the cystic duct. This error usually occurs when the surgeon uses the "infundibular" technique to identify the cystic duct. This technique, which depends on seeing the cystic duct flare as it becomes the infundibulum, is especially prone to be misleading in the face of acute inflammation. This technique is unreliable and should not be used alone for anatomic identification of the ducts. It is preferable to use the critical view technique or to perform a cholangiogram.