title: Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective.
abstract: OBJECTIVE
  To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury.
  
  
  BACKGROUND
  Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error.
  
  
  METHODS
  The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations.
  
  
  RESULTS
  The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot.
  
  
  CONCLUSIONS
  These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.
authors.affiliation: Department of Surgery, University of California-San Francisco, 513 Parnassus Avenue, S-550, San Francisco, CA 94143-0475, USA.
authors.forename: Lawrence W
authors.initials: LW
authors.lastname: Way
authors.forename: Lygia
authors.initials: L
authors.lastname: Stewart
authors.forename: Walter
authors.initials: W
authors.lastname: Gantert
authors.forename: Kingsway
authors.initials: K
authors.lastname: Liu
authors.forename: Crystine M
authors.initials: CM
authors.lastname: Lee
authors.forename: Karen
authors.initials: K
authors.lastname: Whang
authors.forename: John G
authors.initials: JG
authors.lastname: Hunter
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000293:injuries*; D019336:Cognitive Science; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000145:classification / Q000209:etiology* / Q000517:prevention & control*; D010535:Laparoscopy; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D014741:Video Recording