Surgical Accidents

Evaluating the Laparoscopic Cholecystectomy Case (continued)

If a surgeon cannot confirm the site of the juncture of the cystic and common bile duct, the surgeon should perform a cholangiogram, where a radio-opaque substance is injected through a catheter into the cystic duct. The dye should move freely to the juncture of the cystic and common bile duct and then fill both the common bile duct and common hepatic duct. Because a metal radio-opaque clip is placed at the cystic duct proximal to the area where the catheter is introduced during a cholangiogram, the surgeon can readily ascertain the proximity of the clip to the dye within the bile ducts and can also readily identify the juncture of the cystic duct and common bile duct.

Ironically, even though the surgeon performs a cholangiogram prior to dividing the common bile duct, the cystic duct is nonetheless misidentified. Though in most facilities a radiologist will be shown the cholangiogram intraoperatively before the surgeon divides the cystic duct, this additional consultation often is unavailing because, incredibly, radiologists and surgeons do not speak to each other. In many hospitals, a technologist will either orally covey the radiologist's communication to the surgeon or hand the surgeon a scrawled handwritten note of the radiologist.

Appropriate standards of practice for radiologists interpreting cholangiograms require that they immediately notify a surgeon if the flow of dye does not fill both the common bile duct and common hepatic duct. Sometimes both are not filled because inadequate dye has been injected. Sometimes the failure of the dye to fill the common hepatic duct is due to the positioning of the patient on the table. Appropriate standards of practice require that if the common hepatic duct is not filled with dye, the operative table upon which the patient is lying should be placed in the Trendelenburg (head-down) position. Finally, appropriate standards also require that if, notwithstanding all of these efforts, one cannot visualize both the common bile duct and common hepatic duct being filled with dye, the surgeon must forego the laparoscopic procedure and perform open surgery. By opening the area, the surgeon will be able to visualize the reason for the abnormal appearance of the cholangiogram.

[ Back to Previous Page ] [ Continue to Page 4 of 4 ]