title: Exposure for laparoscopic cholecystectomy dissection adversely alters biliary ductal anatomy.
abstract: 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 cholecystectomy (LC), as initially described, is done with cephalad traction on the 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 percutaneous introducer placed anterior to the gallbladder. Exposure of Calot's triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured 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 degrees, 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 were 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 (1) extra-hepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot's triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.
authors.affiliation: Department of Surgery, University of Colorado Health Sciences Center, Denver 80262, USA.
authors.forename: R C
authors.initials: RC
authors.lastname: McIntyre
authors.forename: D D
authors.initials: DD
authors.lastname: Bensard
authors.forename: G V
authors.initials: GV
authors.lastname: Stiegmann
authors.forename: N W
authors.initials: NW
authors.lastname: Pearlman
authors.forename: J
authors.initials: J
authors.lastname: Durham
mesh_terms: D001653:Bile Ducts, Intrahepatic / Q000000981:diagnostic imaging / Q000473:pathology; D002758:Cholangiography; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D003287:Contrast Media; D003549:Cystic Duct / Q000000981:diagnostic imaging / Q000473:pathology*; D004210:Dissection; D005704:Gallbladder / Q000473:pathology; D006500:Hepatic Duct, Common / Q000000981:diagnostic imaging / Q000473:pathology*; D006801:Humans; D007482:Iothalamate Meglumine; D016037:Single-Blind Method; D014143:Traction
chemical_list: D003287:Contrast Media; D007482:Iothalamate Meglumine