title: Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy.
abstract: BACKGROUND
  Correct assessment of biliary anatomy can be documented by photographs showing the "critical view of safety" (CVS) but also by intraoperative cholangiography (IOC).
  
  
  METHODS
  Photographs of the CVS and IOC images for 63 patients were presented to three expert observers in a random and blinded fashion. The observers answered questions pertaining to whether the biliary anatomy had been conclusively documented.
  
  
  RESULTS
  The CVS photographs were judged to be "conclusive" in 27%, "probable" in 35%, and "inconclusive" in 38% of the cases. The IOC images performed better and were judged to be "conclusive" in 57%, "probable" in 25%, and "inconclusive" in 18% of the cases (P < 0.001 compared with the photographs). The observers indicated that they would feel comfortable transecting the cystic duct based on the CVS photographs in 52% of the cases and based on the IOC images in 73% of the cases (P = 0.004). The interobserver agreement was moderate for both methods (kappa values, 0.4-0.5). For patients with a history of cholecystitis, both the CVS photographs and the IOC images were less frequently judged to be sufficient for transection of the cystic duct (P = 0.006 and 0.017, respectively).
  
  
  CONCLUSIONS
  In this series, IOC was superior to photographs of the CVS for documentation of the biliary anatomy during laparoscopic cholecystectomy. However, both methods were judged to be conclusive only for a limited proportion of patients, especially in the case of cholecystitis. This study highlights that documenting assessment of the biliary anatomy is not as straightforward as it seems and that protocols are necessary, especially if the images may be used for medicolegal purposes. Documentation of the biliary anatomy should be addressed during training courses for laparoscopic surgery.
authors.affiliation: Department of Surgery, Division of Abdominal Surgery, University Medical Center Groningen, Postbox 30.001, 9700 RB, Groningen, The Netherlands.
authors.forename: K T
authors.initials: KT
authors.lastname: Buddingh
authors.forename: A N
authors.initials: AN
authors.lastname: Morks
authors.forename: H O
authors.initials: HO
authors.lastname: ten Cate Hoedemaker
authors.forename: C B
authors.initials: CB
authors.lastname: Blaauw
authors.forename: G M
authors.initials: GM
authors.lastname: van Dam
authors.forename: R J
authors.initials: RJ
authors.lastname: Ploeg
authors.forename: H S
authors.initials: HS
authors.lastname: Hofker
authors.forename: V B
authors.initials: VB
authors.lastname: Nieuwenhuijs
mesh_terms: D002758:Cholangiography / Q000592:standards*; D002761:Cholangitis / Q000473:pathology / Q000601:surgery; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002764:Cholecystitis / Q000473:pathology / Q000601:surgery; D003135:Common Bile Duct / Q000033:anatomy & histology / Q000293:injuries; D003549:Cystic Duct / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery; D004282:Documentation / Q000592:standards*; D042882:Gallstones / Q000601:surgery; D006801:Humans; D007430:Intraoperative Care / Q000379:methods / Q000592:standards; D007431:Intraoperative Complications / Q000517:prevention & control; D015588:Observer Variation; D010195:Pancreatitis / Q000601:surgery; D010781:Photography / Q000592:standards*; D012189:Retrospective Studies