Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

J Hepatobiliary Pancreat Sci. 2017 Nov;24(11):591-602. doi: 10.1002/jhbp.503. Epub 2017 Oct 23.


Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

Keywords: Bile duct injury; Critical view of safety; Delphi consensus; Laparoscopic cholecystectomy; Surgical difficulty.

Publication types

  • Letter
  • Multicenter Study

MeSH terms

  • Bile Ducts / injuries*
  • Cholecystectomy, Laparoscopic / adverse effects*
  • Cholecystectomy, Laparoscopic / methods
  • Consensus
  • Delphi Technique
  • Female
  • Humans
  • Iatrogenic Disease / epidemiology*
  • Intraoperative Complications / epidemiology
  • Intraoperative Complications / surgery*
  • Japan
  • Korea
  • Male
  • Surgeons
  • Surveys and Questionnaires*
  • Taiwan
  • United States