Invited Expert Commentary
B. Todd Heniford, MD
Chief, Division of Gastrointestinal and Minimally Invasive
Department of General Surgery
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.