Booij Klaske A C, de Reuver Philip R, Nijsse Bram, Busch Olivier R C, van Gulik Thomas M, Gouma Dirk J
Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
Surgery. 2014 Mar;155(3):384-9. doi: 10.1016/j.surg.2013.10.010. Epub 2013 Oct 12.
In 2007, a Dutch guideline for laparoscopic cholecystectomy (LC) was composed that advocates the critical view of safety (CVS) to prevent bile duct injury (BDI). Conversion to open cholecystectomy is recommended in complicated cholecystectomy, but young surgeons are hardly trained in this procedure. The aim of this study was to analyze the accuracy of dictated operation notes, the use of CVS before and after guideline implementation, and the severity of injury after conversion.
Between 1990 and 2012, 800 patients were referred for treatment of BDI. All available operation notes (n = 528; 66%) were scored for procedural conditions, reasons for conversion, the use of safety measures, and postoperative care in BDI patients.
Patient demographics, indication for cholecystectomy, conversion rates, and injury type were comparable to the total cohort of BDI patients. LC (n = 479; 91%) was converted in 180 patients (34%). The CVS technique or dissection of Calot's triangle were reported in 33 patients (6.3%) and 87 patients (16.5%), respectively. Guideline implementation increased the reporting of CVS from 4% (16/425) to 17% (17/103; P < .001), and the consultation of a hepatic-pancreatic-biliary (HPB) colleague from 3% (14/425) to 8% (8/103; P < .01). Conversion to open surgery leads to more complex injury (Bismuth III-V injury rate of 34% [24/64] vs 65% [46/116]; P = .013).
The insufficient use of safety measures to prevent BDI during LC in this selected patient group is of concern. Although guideline implementation significantly improved the use of CVS during LC, further improvement is necessary. Conversion cannot simply be used as an "escape" procedure, because this may lead to more complex injury.
2007年制定了荷兰腹腔镜胆囊切除术（LC）指南，提倡采用安全关键视野（CVS）以预防胆管损伤（BDI）。对于复杂的胆囊切除术，建议转为开腹胆囊切除术，但年轻外科医生很少接受该手术的培训。本研究的目的是分析口述手术记录的准确性、指南实施前后CVS的使用情况以及转为开腹手术后损伤的严重程度。
1990年至2012年间，800例患者因BDI接受治疗。对所有可用的手术记录（n = 528；66%）进行评分，评估手术情况、转为开腹手术的原因、安全措施的使用以及BDI患者的术后护理。
患者人口统计学特征、胆囊切除术的适应证、中转率和损伤类型与BDI患者的总体队列相当。180例患者（34%）中转开腹胆囊切除术（n = 479；91%）。分别有33例患者（6.3%）和87例患者（16.5%）报告采用了CVS技术或解剖胆囊三角。指南实施后，CVS的报告率从4%（16/425）提高到17%（17/103；P <.001），肝胰胆（HPB）专科同事的会诊率从3%（14/425）提高到8%（8/103；P <.01）。转为开腹手术会导致更复杂的损伤（Bismuth III - V级损伤率为34%[24/64]对65%[46/116]；P =.013）。
在这个选定的患者群体中，LC期间预防BDI的安全措施使用不足令人担忧。尽管指南实施显著改善了LC期间CVS的使用，但仍有必要进一步改进。中转开腹手术不能简单地用作“逃避”手术，因为这可能导致更复杂的损伤。
