Dissection approach during laparoscopic cholecystectomy and bile duct injuries. A population based register study

Abstract Introduction There have been concerns that laparoscopic cholecystectomies carried out with the fundus first approach are associated with more severe bile duct injuries compared to Calot first. The aim of this study was to assess the impact of dissection approach on the risk of bile duct injuries. Method The study was based on laparoscopic cholecystectomies registered in the Swedish national register for gallstone surgery and ERCP. Bile duct lesions were divided into lesions less than (minor) and more than (major) a third of the circumference, below the cystic duct and lesions to the hepatic duct and above. The risk of bile duct injuries was analyzed with univariate and multivariate logistic regression adjusted for gender, age, acute cholecystitis and dissection approach. Result Altogether 196 023 patients were included (182 514 Calot first and 13 509 Fundus first). Multivariable logistic regression analyses with all bile duct injuries as outcome showed OR: 2.60 (p < 0.001) for Fundus First compared to Calot first. With major bile duct injuries as outcome the OR: 3.57 (p < 0.001). With bile duct injuries below the cystic duct as outcome the OR: 1.51 (p 0.039) and with bile duct injuries above the cystic duct as outcome the OR: 4.05 (p < 0.001). Discussion There is an association between dissection approach and risk for bile duct injuries, especially major bile duct injuries and bile duct injuries above the cystic duct. This might depend on the experience amongst surgeons since the Fundus first technic is often used as a rescue procedure in complex cases.