5 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M A Y 2 0 1 9
The primary cause of
error in the vast
majority of BDIs? Not
poor technical skills
or a lack of knowl-
edge on the sur-
geon's part, but visu-
al perceptual illu-
sions, meaning the
surgeon deliberately
cut the common duct, erroneously believed to be the cystic duct.
Here are a couple ways to improve visualization.
• ICG exposure. An injection of indocyanine green (ICG) dye just
before you start the case can help. Once you inject ICG, near
infrared imaging picks it up as it illuminates structures such as
the cystic duct and the common bile duct. In some cases, so-
called "ICG exposure" lets you better visualize the biliary tract so
you can safely transect the cystic duct and avoid any injury to the
common bile duct.
• Operative cholangiogram. In an intraoperative cholan-
giogram, you transect the cystic duct, see a catheter through the
cystic duct into the common bile duct and then inject a radio
opaque contrast material. Cholangiograms let you visualize the
common bile duct stones. There are drawbacks to this tech-
nique: it takes more time, a little more equipment, and it expos-
es you and your team to radiation.
— Salvatore Docimo Jr., DO, FACS
Overcoming 'Visual Perceptual Illusions'
• CRITICAL VIEW Visual misperception causes most of the errors that result in
laparoscopic bile duct injuries, not errors of skill, knowledge or judgment.
BETTER VISUALIZATION
