Causes and Prevention of Laparoscopic Bile Duct Injuries: Analysis of 252 Cases From a Human Factors and Cognitive Psychology Perspective

TLDR: It is shown that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

Abstract: Bile duct injuries are the main serious technical complication of laparoscopic cholecystectomy. 1,2 Data are insufficient to determine precisely the frequency of bile duct injuries, but a reasonable estimate is one in 1,000 cases. 2 A decade ago, as the technique of laparoscopic cholecystectomy was first being learned by otherwise fully trained, practicing surgeons, the injury rate was noted to be greater during an individual’s first dozen cases than in subsequent ones. 2 This learning curve contribution is now much less important, for surgical residents learn the procedure under direct supervision of more experienced surgeons. Surgeons have always analyzed their technical complications for insights that might be translated into improved performance. In the past the information available from such reviews could rarely go much beyond a tabulation of results. An understanding of the root causes of technical complications remained elusive. This report takes analysis of technical complications to greater depths, for it integrates the findings of videotapes of operations involving bile duct injuries, operative notes dictated after the operation had been completed but before an injury had become apparent, and conceptual tools of human factors research and the cognitive science of human error.