Marking the “cystic duct” with 3 radio-opaque titanium clips, then performing a cholangiogram via the gallbladder, allows the surgeon to complete a proof of anatomic identity before dividing the duct in question. Performing the cholangiogram via the gallbladder is usually simpler and faster than through the cystic duct and is useful for surgeons in community and rural hospitals. “Cystic duct” cannulation can be very challenging and may presume foreknowledge of identity that could be erroneous.

For further details, see the August issue of the Journal of the American College of Surgeons (Duff WM. Avoiding misidentification injuries in laparoscopic cholecystectomy: use of cystic duct marking technique in laparoscopic cholangiography. JACS 2006;203:257-261).

Dr. Duff is in the Department of Surgery, Lake Regional Health Systems, Osage Beach, Mo. He can be reached at

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Invited Expert Commentary

B. Todd Heniford, MD

Chief, Division of Gastrointestinal and Minimally Invasive Surgery
Department of General Surgery
Carolinas Medical Center
Charlotte, N.C.

In the manuscript “Avoiding Misidentification Injuries in Laparoscopic Cholecystectomy: Use of Cystic Duct Marking Technique in Intraoperative Cholangiography” (Duff WM. JACS 2006;203:257-261), Dr. Duff describes another technique that can possibly aid a surgeon in correctly identifying the cystic duct during laparoscopic cholecystectomy. The method is well depicted and is illustrated with pictures and operative cholangiograms that demonstrate anatomic variance that he has encountered over a 2-year period. Independently, the systems of marking the cystic duct prior to radiograph and cholecystocholangiography are not new, but the combination probably is.

In attempting to reproduce this procedure in the operating room, there are several technical difficulties. First, during cholangiography surgical retraction of the gallbladder needs to be maintained to prevent the “accordion effect,” in which the gallbladder falls back into its anatomic location. Given this, the instruments need to be maintained in position while the cholangiogram is performed. It is somewhat difficult to bring in the fluoroscope with the graspers extending out of the abdomen due to their height. Even with maintenance of retraction, the contrast-filled gallbladder tends to overshadow the clips. Obviously, rolling the patient right-side down can help shift the gallbladder out of the line between the fluoroscope and the cystic duct/common duct, but this adds to the difficulty in maintaining the spinal needle in the correct position within the gallbladder lumen; it is very easy with a sharp needle in a moving target to go through the wall of the gallbladder or to pull it out.

Dr. Duff’s description of using full-strength contrast to delineate small ducts is sound, but full-strength dye can also mask common bile duct stones, leaving us somewhat more likely to miss them at the time of surgery. Lastly, the patients who perhaps need it most, those with an obstructed cystic duct or significant inflammation in the portohepatic area, do not appear to be candidates for this procedure.

Dr. Duff’s technique certainly falls into the category of helpful but not ideal. This along with the technique of the “critical window,” placing a single clip on the cystic artery prior to cholangiography, top down technique, etc., all add to our armamentarium of “tricks” during laparoscopic cholecystectomy.

Response from Dr. Duff:

I have found this technique useful in acute cholecystitis and in instances of obstruction of the gallbladder and cystic duct. The contrast will often go around the obstruction. One useful tip is to rotate the C-arm 15 degrees and then it is not necessary to rotate the patient to the right so much. This is more than a trick, but a useful day-to-day technique to help improve the safety of laparoscopic cholecystectomy. It does take time to master. Remember, humility is only one case away.