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INTRODUCTION
Bile duct injury (BDI) is the most serious of all complications during laparoscopic cholecystectomy (LC). It leads to significant mortality and morbidity, even following a successful repair. Misidentification of the bile duct as a cystic duct is the main cause of ductal injury. Despite recognition of the importance of correct cystic duct identification in prevention of BDI, the UK practice lacks an agreed systematic method for "Safe Cystic Duct Identification". The aim of this questionnaire is to survey terms used to describe the techniques utilised for intra-operative anatomical identification of the cystic duct among practising UK hepatobiliary surgeons and members of ALS (Association of Laparoscopic Surgeons).
METHOD
A postal questionnaire and an electronic one were sent to all UK specialist hepatobiliary surgeons and to ALS members respectively. The questionnaire was designed to allow the user to select the descriptive terms that best fit the method used for cystic duct identification during LC. The survey was constructed utilizing SAGE's (Society of American Gastrointestinal and Endoscopic Surgeons) recommendations and included "Triangle of Calot is Displayed Clearly", "Triangle of Calot is Displayed Clearly Anteriorly and Posteriorly", "Confluence of Cystic to Common Hepatic Duct Displayed", "Infundibular Technique Utilized", "and Critical View of Safety Demonstrated". Surgeons were invited to add any comments or recommendations.
RESULTS
74 postal questionnaires (72.5% return) from consultant HPB surgeons were completed and returned. The most prevalent descriptive term or terms used to describe intraoperative cystic duct identification methodology included "triangle of Calot is displayed clearly anteriorly and posteriorly" and "critical view of safety demonstrated" (72% selection rate) followed by "infundibular technique utilized" (49% selection rate). The majority of additional comments related to utilization of intra-operative fluorocholangiography when anatomy is in doubt and to avoid clipping or cutting until the anatomy is clear. 133 electronic questionnaires were completed by 6 Clinical Fellows (4.5%), 28 ST/SpRs (21.2%) and 98 Consultants (74.2%). The frequency of descriptive terms used was as follow: ‘Calot's Triangle identified & Demonstrated' (70.8%) followed by ‘Demonstration of Strasberg's Critical View of Safety' (24.2%) and lastly ‘Infundibular technique' (5%).
CONCLUSION
Clear anterior and posterior view of Calot's triangle, display of critical view of safety and demonstration of cystic duct-gallbladder Junction (infundibular technique) are necessary to prevent intraoperative cystic duct misidentification during laparoscopic cholecystectomy.
Intra-operative fluorocholangiography is recommended when anatomical identification is in doubt and no clipping or cutting is performed until the anatomy is verified.