Nationwide Initiative Aims To Reduce Biliary Injuries

L. Michael Brunt, MD, left, leads a national initiative to improve the safety of gallbladder removal procedures, with key contributions from colleague Steven Strasberg, MD, right.

The rate of bile duct injuries associated with laparoscopic gallbladder removal is low: between 0.2 and 0.4 percent. But bile duct injuries can be devastating, and between 2,000 and 3,000 people in the United States are affected each year by injuries that occur in minimally invasive procedures. L. Michael Brunt, MD, a nationally recognized endoscopic surgeon and chief of minimally invasive surgery at Washington University and Barnes-Jewish Hospital, has helped launch a nationwide initiative to reduce injuries and create a universal culture of safety regarding the procedure, called a cholecystectomy.

“Bile duct injuries can lead to liver damage and may require complex reconstruction of the biliary system,” says Brunt. “We know the quality of life and even the survival rate is not as good for patients who have bile duct injuries as for those with an uncomplicated course.”

Brunt started a safe cholecystectomy task force when he was president-elect of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in 2013-14. The task force has now adopted a six-step approach. The first step is to use the Critical View of Safety (CVS) method of identifying anatomic structures during cholecystectomy, a method developed by Washington University hepatobiliary-pancreatic surgeon Steven Strasberg, MD, in 1995 to reduce bile duct injuries when laparoscopic cholecystectomy was first introduced.

Three criteria are required to achieve CVS. Fat and fibrous tissue is cleared; the lower one third of the gallbladder is separated from the liver; and two and only two structures should be seen when entering the gallbladder. The method has proven successful in thousands of reported cases. The other steps are: Consider an intraoperative time-out before clipping, cutting or transecting any ductal structures; understand the potential for anatomic variation; make liberal use of imaging; recognize when the procedure is becoming risky and finish by a safe alternate method if needed; and get help from another surgeon when necessary.

The task force presents the program at surgical meetings and through a web-based educational program, journal articles and social media. “I am convinced that we can have an impact and reduce the rate of biliary injuries,” says Brunt.

Read more about the SAGES Safe Chole Program at


For colleagues nationwide, minimally invasive surgeons in the section are offering an enhanced version of the section’s existing training in laparoscopic inguinal hernia repair. Rather than a one- or two-day class, the post-graduate course takes place over several months and includes mentoring over time. Participants start in the surgery training lab, shown at right, observe complex surgeries and then return to the lab for more practice. Minimally invasive surgeons L. Michael Brunt, MD, and Jeffrey Blatnik, MD, later travel to the surgeons’ hospitals, spend a day watching trainees perform the surgery and provide a critique. Instructors also make themselves available for later consultation. The new approach may encourage more widespread adoption of laparoscopic techniques.

Washington University is participating in a clinical trial of infrared fluorescent cholangiography as a possible way to improve imaging during gallbladder removal. A fluorescent agent is administered before surgery, and a special laparoscopic imaging system enables the surgeon to use conventional light or infrared imaging to view the biliary system. The technique will be evaluated to see whether it can better map the biliary anatomy during surgery, reducing biliary injuries and enhancing safety.

The section is treating more patients with complex abdominal wall hernias, due in part to the obesity epidemic. In many cases, the patients have had multiple failed repairs with various types of mesh and surgical techniques, along with increased rates of adhesions and scar tissue. Among the repair techniques used are laparoscopic and robotic procedures and, for patients with large hernias who are not candidates for a minimally invasive approach, open posterior component separation.