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Introduction: The most common mechanism of major bile duct injury (BDI) involves misidentification of the CBD as the cystic duct, which is then deliberately transected. A common, but less frequent, mechanism occurs when the hepatic duct is injured during dissection in the triangle of Calot that is unknowingly too close to the common hepatic duct. Both mechanisms involve misperception, but one is active and the other passive. We analyzed the two to find clues that would help improve prevention.
Methods: 433 lap cholecystectomies (125 uncomplicated, 308 BDI) were studied. BDI were categorized according to the type: active (deliberate transection of common bile duct mistaken for the cystic duct) and passive (lateral injuries during dissection too close to the common hepatic duct). Operative reports were examined for sensemaking cues and clinical factors.
Results: Of the 308 BDI: 223 (72%) were active (ActBDI), 77 (25%) were passive (PassBDI), and 8 (3%) followed CBDE with T-tube. The level of biliary injury is shown in the second table; injury to proximal bile ducts was more common with ActBDI. Fewer PassBDI (16%) than ActBDI (34%) were recognized intra-op (P=0.006). Factors limiting visibility (inflammation, bleeding, etc) were more common in PassBDI (Table); while what were thought to be abnormal anatomic findings (additional ductal/tubular structures, arteries, vessels, abnormal biliary anatomy) were more common in ActBDI (Table). The surgeon’s intra-operative sense-making also differed: a deliberate search for possible BDI was more common in ActBDI than in PassBDI (Table); cases were more commonly opened for compromised visibility with PassBDI (Table); and ActBDI were more commonly identified intra-op among all BDI cases as well among those converted to a laparotomy. Certain cues inhibited BDI detection. Detection of all BDI was less common in cases with bleeding (9% vs 36%, bleeding vs none, P<0.0001), and when multiple factors limited visibility (BDI detection: 35% no visibility issues, 28% one issue, but only 11% with two or more factors limiting visibility, P<0.0001).
Conclusions: This study highlights differences in BDI mechanisms and possible means of prevention. Most surgeons are aware of the perceptual trap of misidentifying the CBD for the cystic duct, but passive injury has been less completely elucidated. These data show that PassBDI were less often detected, and identification of all BDI was hindered when visibility was impaired (mainly by bleeding or inflammation). Thus, when the surgeon’s attention was occupied by inflammation or bleeding, consideration of an injury to the bile duct was inhibited. Increased emphasis on this risk factor should help prevent passive injury to the common hepatic duct.

Active and Passive BDI Characteristics

		Active BDI N = 223	Passive BDI N = 77	No BDI N = 125	P Value
Visibility issues	Bleeding	35(17%)*	28(36%)*	7(6%)*	< 0.0001
	Inflammation	75(34%)	45(58%)*	39(31%)	< 0.0001
	One or more	81(36%)	63(82%)*	43(34%)	< 0.0001
Irregular Anatomic Cues	Extra / Abnormal Artery or Vessel	87(39%)*	18(23%)*	11(9%)*	< 0.02
	Extra Bile Duct / Tubular Structure	5 9(26%)*	3(4%)	1(1%)	< 0.0001
	Abnormal Biliary Anatomy	76(34%)*	13(17%)	11(9%)	< 0.008
Surgeon Sensemaking	Search BDI	43(19%)*	4(5%)	0	0.006
	Identify BDI	75(34%)*	12(16%)	0	0.004
	Open visibility issues	15(7%)	20(26%)*	0	< 0.0001
	Open concern anatomy / BDI	17(8%)	1(1%)	0	0.085
	BDI identify w/conv open	18/32 (56%)*	5/21(23%)	--	0.026

* Significant factors BDI = bile duct injury

Distribution of Injuries

	CBD / CHD	Bifurcation	Above Bifurcation	Involvement Lobar Ducts	Isolated Right ductal injury
Active BDI	139(62%)	30(13%)	26(12%)	11(5%)	17(8%)
Passive BDI	57(74%)	6(8%)	1(1%)	0	13(17%)
BDI after T-tube	8(100%)	0	0	0	0