Anatomical delineation of the biliary tree during laparoscopic cholecystectomy by intracholecystic injection of methylene blue

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Abstract

Background
Many factors have been incriminated in occurrence of bile duct injuries during laparoscopic cholecystectomy (LC). Misidentification of the anatomy and lack of surgeon’s experience seems to be preliminary; however, many techniques were used to avoid such injuries.
Aim of the work
To asses feasibility of delineation of biliary tree by intracholecystic injection of methylene blue (MB) during LC.
Patients and methods
A prospective study had been conducted in Ain Shams University Hospitals between January 2019 and January 2020. The study included 60 patients who presented to outpatient department (OPD) with abdominal ultrasound showing chronic calcular cholecystitis and all underwent intracholecystic injection of MB during LC.
Results
As regards MB delineation of different parts of gall bladder and biliary tract component, gall bladder delineation occurred in all patients (100%), whereas cystic duct delineated in 80% of patients (48/60) and common bile duct (CBD) delineated in 41.7% of patients (25/60) as general and separate assessment of each element alone with no detected cases of bile duct injury. There was significant increase in CBD delineation in patients with single stone and thin-walled gall bladder. Extravasation of dye from the gall bladder into the abdominal cavity occurred and this led to anatomical misidentification and significant prolongation of operative time (extra time was needed for irrigation and suction).
Conclusion
The technique by which the MB is injected into the lumen of gall bladder to delineate the cystic duct and CBD is feasible, cheap, and performed without any radiation exposure and without using special equipment. By this technique, no cases of biliary injury were detected; however, critical view of safety remains the gold standard surgical technique to prevent bile duct injury.

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