Bile duct injuries (BDI) during laparoscopic cholecystectomy are still common. To guarantee a safer laparoscopic cholecystectomy (LC), several techniques have been proposed, including intra-operative cholangiography, the use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS).We supplement these with posterior infundibular dissection, which is the first surgical procedure performed during LC.[1-2]. When compared to open cholecystectomy (OC) (0.1–0.2%), the incidence of BDI in LC was startlingly high (0.5–0.7%) in the early stages of the procedure [3–5]. Thankfully, current research indicates that the rate of BDI in the advanced laparoscopic age is comparable to OC (0.2%) [6,7]. Misidentification of the anatomical features during the technique is one of the most frequent causes or mechanisms of BDI in LC [8–10]. The critical view of safety (CVS) idea is the most commonly accepted strategy to prevent BDI. The CVS concept identifies the cystic duct and cystic artery, separates the gallbladder's lower third from the cystic plate, and removes all tissue from the hepatocystic triangle, leaving just two structures visible prior to transection. Surgeons are less likely to use alternative surgical methods and procedures, such as infudibulo-cystic or infundibular, fundus-down, subtotal cholecystectomy without visibility of the CVS [12–14]. The CVS idea does not completely eradicate BDI, for instance, via direct harm in severe inflammatory situations, even though it lessens BDI by misidentification [15].An version of the so-called infundibular view approach (ductal identification by exposing the infundibulo-cystic junction) is often employed in our tertiary teaching hospital. However, utilizing this technique in individuals with very inflamed gallbladders and/or those with abnormal ductal architecture has generated serious concerns [15]. However, there is a lack of evidence on BDI from a large cohort utilizing a consistent infundibular technique. This retrospective single-center cohort research used a standardized posterior infundibular technique to examine the prevalence, severity, and treatment of BDI.

A retrospective study was carried out at Pir Abdul Qadil Shah Jeelani Institute of Medical Sciences, Gambat from January 2023 to March 2025. This Study was approved by Institutional Research ethical Committee. Patients with LC concurrently with another procedure or for cancer-related causes were not included. Comorbidities were recorded using the Elixhauser Comorbidity Index in accordance with the International Classification of Diseases and Related Health Problems (ICD-9 and ICD-10) [16]. All patients who underwent hepatobiliary surgery or an endoscopic retrograde cholangiopancreatography (ERCP) following cholecystectomy were identified using a surgery- and procedure-specific code and thoroughly examined in order to find individuals with BDI within the database. For these patients, a subgroup analysis was carried out. According to the Strasberg classification, the kind of BDI was determined [11]. BDI patients who were referred from other facilities were not included in this research. The Clavien-Dindo grading system was used to categorize the degree of problems following BDI repair, with grade 3 or above denoting significant issues [17]. Every procedure carried out on the patients in this research complied with the institution's ethical guidelines. On the Other hand, Frequency (n) and percentage (%) are used to report categorical variables. The mean (standard deviation; SD) or median (range) are used to characterize continuous variables. Patients with BDI were monitored until they passed away or until the January 2023 trial end date. Patients with BDI in LC had a median follow-up period of 24 months. Different Statistical tools were used to perform statistical analyses. Surgical Techniques The patient is placed in a supine position with their legs abducted. The patient and the surgeon are positioned between their legs. Using a Veres needle at Palmer's point, a CO2-pneumoperitoneum is created until the intraabdominal pressure reaches 15 mmHg. A 12 mm trocar is positioned at the umbilicus, a 5 mm trocar in the left hypochondrium at the midclavicular line, a 5 mm trocar in the right subcostal area at the midclavicular line, and a 5 mm trocar farther laterally on the right flank. For the remainder of the surgery, intra-abdominal pressure is lowered to 8–12 mmHg following trocar installation in order to provide enough room for a laparoscopic view. The posterior hepatocystic triangle is best exposed when the gallbladder is retracted cephalad at the fundus and the infundibulum is pushed medially. Using monopolar electrocautery, the hepatocystic triangle is dissected, and the peritoneal envelope is first cut posteriorly, staying as close as possible to the infundibulo-cystic connection—the lowest border of the gallbladder infundibulum that connects to the upper border of the cystic duct. The cystic duct is released from its peritoneum at this level onto the anterior and medial sites of the infundibulo-cystic connection upon visualization of the posterior infundibulo-cystic connection. This creates a dissected region circumferentially around the infundibulo-cystic connection. In the direction to the gallbladder, the cystic duct is snipped. A selective intraoperative transcystic cholangiography is carried out when there is a suspicion of bile duct stones prior to surgery (bile duct distention on ultrasound, abnormal liver function tests), during the procedure (diameter of the cystic duct measuring at least 5 mm), or when there is unclear biliary anatomy or suspicion of bile duct injury. When a cholangiogram reveals verified bile duct stones, a transcystic technique is used to retrieve the stones using a flexible cholangioscope. Next, two Hem-O-Lok clips are used to clamp the cystic duct in the direction of the main bile duct before it is transected. Following the transection of the cystic duct, the gallbladder is dissected anteriorly to reveal and dissect the cystic artery once it has been released from the peritoneal sheath. One Hem-O-Lok clip is used distally and two proximally to clip the cystic artery, which is then transected. Cholecystectomy is finally finished from the infundibulum toward the fundus, being careful to keep the dissection as near to the gallbladder as feasible at all times. Following specimen extraction via the umbilical trocar site, hemostasis is managed, the pneumoperitoneum is deflated, and the trocars are withdrawn without a drain being routinely placed.

A laparoscopic cholecystectomy was performed on 117 consecutive patients with symptomatic cholelithiasis during the research period. The average age was 55 (SD + 17) years, and the male-to-female ratio was 47/70. Table 1 showes LC indications as well as patients' comorbidities. 51 patients (59.67%) were LC done in an emergency situation. 12(14.04%) patients underwent intraoperative cholangiography with laparoscopic exploration of the common bile duct, and 54 patients (63.18%) underwent surgery in an outpatient clinic. The postoperative mortality rate for all patients undergoing LC was n=14 (16.38%). Preoperative-existing septic shock (n = 1), small bowel ischemia (n = 2), multiorgan failure after spontaneous hematoma of the abdominal rectus muscle (n = 1), respiratory insufficiency (n = 2), cardiac arrest (n = 3), hypoglycemic coma (n = 1), end-stage chronic renal failure (n = 1), septic shock after duodenal perforation (n = 1), and hemorrhagic shock (n = 1). Chronic cholecystitis was the most frequent cause of laparoscopic cholecystectomy (65 patients, 76.05%), followed by obesity (28 patients, 32.76%) and acute cholecystitis (26 patients, 30.42%). Cholecystolithiasis (20 patients, 23.4%), weight loss (11 patients, 12.87%), rheumatoid arthritis (7 patients, 8.19%), liver disease (4 patients, 4.68%), choledocholithiasis (4 patients, 4.68%), and peptic ulcer disease (3 patients, 3.51%) were among the less frequent reasons and comorbidities. Cholangitis and AIDS were not reported (0%), but rare indications or comorbidities like pancreatitis, acute cholecystitis with choledocholithiasis, chronic blood loss anemia, congestive heart failure, coagulopathy, solid tumors with metastases, depression, deficiency anemia, and drug abuse were each seen in 1-2 patients (1.17–2.34%). Table 1: Patients’ Characteristics Cholecystolithiasis 20 (23.4%) Chronic Cholecystitis 65 (76.05%) Acute Cholecystitis 26(30.42%) Choledocholilithiasis 04(4.68%) Pancreatitis 01(1.17%) Cholangitis 00(0.00%) Acute cholecystitis & Choledocholithiasis 01(1.17%) AIDS 0(0.00%) Drug Abuse 02(2.34%) Deficiency anemia 02(2.34%) Rheumatoid Arthritis 07(8.19%) Chronic blood Loss anemia 01(1.17%) Congestive Heart Failure 01(1.17%) Chronic Pulmonary Disease 02(2.34%) Coagulopathy 01(1.17%) Depression 03(3.51%) Obesity 28(32.76%) Liver Disease 04(4.68%) Solid Tumors with Mets 03(3.51%) Peptic Ulcer Disease 03(3.51%) Weight Loss 11(12.87%) In Table 2, Sixteen patients (18.72%) with bile duct injuries were involved in this study. With a range of 30 to 83 years, the cohort's median age was 57, suggesting a very broad age spread. Ten females (62.5%) and six men (37.5%) made up the research population, indicating a small female preponderance. The majority of patients seemed to be overweight based on traditional BMI classification, as shown by the median body mass index (BMI) of 26.5 kg/m² (range: 16.8–35).The ASA classified patients based on their preoperative physical status: 4 patients (25.0%) were ASA I, 10 patients (62.5%) were ASA II, and 2 patients (12.5%) were ASA III. These results showed that the majority of patients had mild systemic disease but were surgically fit. In terms of the surgical context, seven patients (43.75%) needed emergency treatments because of acute presentations, whereas nine patients (56.25%) received elective laparoscopic cholecystectomy. During the index procedure, two patients (12.5%) had laparoscopic common bile duct exploration (LCBDE), while five patients (31.25%) underwent intraoperative cholangiography (IOC). Notable intraoperative complications included vascular damage in one patient (6.25%) and iatrogenic gallbladder perforation in ten patients (62.5%). Twelve patients (75.0%) had cholecystitis at the time of surgery, indicating that inflammatory pathology was present in most of them. Two patients (12.5%) required conversion to laparotomy during the index procedure, indicating difficult operating circumstances. The most prevalent form of bile duct injuries (BDI) was type A (8 patients, 50.0%), which was followed by type C (4 patients, 25.0%), type D (2 patients, 12.5%), type E1 (1 patients, 6.25%), and type E2 (1 patient, 6.25%). According to this distribution, complicated injuries (types D and E) were less common but clinically important, while the majority of injuries were mild (type A). Table 2: Patients’ Characteristics Bile Duct Injury-Subgroups Variables n=16 Age (year, median, range) 57(30-83) Gender Male Female 06(37.5%) 10(62.5%) BMI(kh/m2, median, range) 26.5(16.8-35) ASA Classification I II III 04(25.0%) 10(62.5%) 02(12.5%) Setting of Surgery Elective Emergency 09(56.25%) 07(43.75%) IOC at index operation Yes No 05(31.25%) 11(68.75%) LCBDE at index operation Yes No 02(12.5%) 14(87.5%) Iatrogenic GB Perforation Yes No 10(62.5%) 05(31.25%) Vascular Injury at index operation Yes No 01(6.25%) 15(93.75%) Cholecystitis present at index operation Yes No 12(75.0%) 04(25.0%) Conversion of Laparotomy during index operation Yes No 02(12.5%) 14(87.5%) Type of BDI According to Strasberg Classification A C D E1 E2 08(50.0%) 04(25.0%) 02(12.5%) 01(6.25%) 01(6.25%) In Table 3, Analysis was done on 16 individuals who had bile duct damage (BDI) repaired. The majority of repairs were completed quickly, as seen by the median time from BDI diagnosis to repair of 0 days (range: 0–45 days). Similarly, there was variation in the time of intervention, as seen by the median gap of 0 days (range: 0–132 days) between laparoscopic cholecystectomy and BDI repair. Endoscopic repair was the most often used technique for BDI repair (10 patients, 62.5%), followed by ERCP with stent implantation (12 patients, 75.0%). Four patients (25.0%) had laparoscopic repair. Additional repair methods included intrahepatic hepaticojejunostomy (4 patients, 25.0%), laparotomy with primary suture on a Kehr drain (3 patients, 18.75%), primary suture (1 patient, 6.25%), suture of the duct of Luschka (1 patient, 6.25%), and clip removal (1 patient, 6.25%). This illustrates a mix of surgical and endoscopic techniques based on the kind and severity of BDI. After BDI repair, some individuals had complications. These included biliary tract perforation during ERCP in one patient (6.25%), duodenal perforation in two patients (12.5%), hemorrhage in one patient (6.25%), and biliary stenosis in three patients (18.75%). Six patients (37.5%) had problems of grade >3, which denotes serious complications needing radiological, endoscopic, or surgical intervention, according to the Clavien-Dindo classification. Two patients (12.5%) needed to be admitted to the critical care unit, whereas the rest (14 patients, 87.5%) did not need such treatment after the repair. Table 3: Characteristics of BDI management and Outcomes Variables n=16 Time b/w BDI diagnosis and Repair (days, median, range) 0(0-45) Time b/w LC and BDI Repair (days, median, range) 0(0-132) Type of Repairs Endoscopic ERCP with settings Laparoscopic Primary Suture Suture duct of Luschka Removal clips Laparotomy Primary suture on Kehr drain Intrahepatic hepaticojejunostomy 10(62.5%) 12(75.0%) 4(25.0%) 1(6.25%) 1(6.25%) 1(6.25%) 3(18.75%) 1(6.25%) 4(25.0%) Complication after BDI Repair Bleeding Duodenal Perforation Biliary tract perforation after ERCP Biliary stenosis 1(6.25%) 2(12.5%) 1(6.25%) 3(18.75%) Complication grade after BDI Repair Clavien-Dindo classification > 3 6(37.5%) ICU Stay Yes No 2(12.5%) 14(87.5%)

The posterior infundibular approach in LC was linked to a BDI rate of 16/117 (18.72%) at our facility, suggesting that it is a safe and repeatable procedure. The found BDI rate is consistent with previous research [6, 7]. The findings of more than 1000 LC were reported by Avgerinos et al. [18], who recommend using the CVS-method to conduct LCs on a regular basis. Unlike our study, which found that bile leaks occurred in 5 out of 1046 patients (0.48%), they report a 0% BDI rate. The authors employed an infundibular method in 19 of the 48 individuals for whom a CVS could not be achieved.Iskandar et al. have recently reported a similar infundibular method [14]. They hypothesize that using a posterior infundibular technique eliminates the necessity for a thorough hepatocystic triangle dissection. This lessens the possibility of harm to the right hepatic artery, the common hepatic duct, and the right hepatic duct.The remarkable 0% proportion of BDI in 1402 LC is reported. Nevertheless, unlike this study, they did not take bile leakage from the cystic stump into account as a BDI. Only two (1.71%) of the sixteen BDIs in our group were significant BDIs (Strasberg category E1 or E2), including one vascular injury. A minimally invasive method was used to treat the majority of BDIs (87.5%). Similar to our standardized technique, Strasberg et al. [10–12, 15] described a "infundibular technique" in LC and deemed it unreliable when compared to the CVS concept, particularly in cases with acute inflammation where the cystic duct might become "hidden" or in cases with a Mirizzi's syndrome. They claim that applying this method in these situations would cause the cystic duct and the common bile duct to be mistakenly identified. Only four individuals (3.42%) in our study experienced BDI as a result of misidentification. It is hard to determine whether the BDI in these situations might have been prevented by applying the CVS approach. A dependable, consistent method appears to be essential in more challenging situations when the danger of biliary and vascular injuries is much higher [7]. The majority of guidelines for a safe LC propose the CVS, which is supported by several researchers [19–23]. However, it might be challenging to meet all three CVS criteria in individuals with chronic cholecystitis or a highly inflamed gallbladder [11, 15]. Thus, alternatives or bail-out processes may occasionally be required [24]. The most current "safe cholecystectomy" recommendations, which recommend subtotal cholecystectomy for individuals in whom CVS cannot be acquired, also reflect this [22, 23]. Additionally, there seems to be a substantial gap between theory and reality regarding the bile duct identification technique employed during LC [25–27]. Due to its low prevalence, it is challenging to objectively investigate the processes and variables associated with BDI; nonetheless, it is noteworthy that CVS has seldom been reported as the technique of hilar dissection in significant BDI [1, 7, 25, 28]. Surprisingly, a significant portion of the surveyed surgeons completely fail to accurately define the CVS, thus compromising the validity of this idea and the available evidence [26]. Prevention is still crucial, even if some writers think BDI is inevitable in some situations [29]. However, the topic of how to successfully prevent BDI remains unanswered. To address this issue, five worldwide HPB associations have released their most recent recommendations for safe cholecystectomy [23]. However, due to the paucity of high-quality research, many recommendations are still reliant on expert opinion.Training and inexperience (learning-curve effect), local risk factors (inflammation, scarring, surgical hemorrhage, etc.), abnormal anatomy (abnormal right hepatic duct), and equipment failure (heat injury owing to insulation malfunction) are all important risk factors for BDI in LC [10].In the past, experience and learning curves have also been thoroughly investigated as potential causes of BDI. According to certain research, if young, inexperienced surgeons do LC, the BDI rate is three times greater than that of more experienced surgeons [19, 30, 31]. A greater operating difficulty grade was linked to lower outcomes for both experienced and general surgeons, according to Griffiths et al.'s comparison of LC results [30-33]. More intriguingly, compared to a high BDI-rate in the general surgeon group, BDI in patients with a higher operating difficulty grade remained low in the experienced groups. On the other hand, neither group's LC method is stated. Because this is a large teaching hospital, junior surgeons perform the great majority of cholecystectomies in our research. However, our study's BDI rate is similar to that seen in the literature, indicating that even less skilled surgeons may obtain a low BDI rate in LC by employing meticulous dissection based on a standardized approach. Cholecystitis seems to be the most obvious risk factor for BDI during LC in more recent data included a patient sample of 217.774 cases [7]. These results suggest that regardless of the dissection technique, local variables such inflammation and scarring are significant in the development of BDI [7, 22]. The influence of intraoperative cholangiography (IOC) on BDI in LC is a topic of continuous discussion.IOC is only applied in certain situations at our facility.Due to the heterogeneity of IOC indications and the potential for bias in research results and recommendations, it is once more challenging to compare the selective use of IOC across various study groups. Regular use of IOC increases the rate of intraoperative identification of BDI, which may lead to better outcomes, but it does not prevent BDI [23, 32, 33]. Ninety percent of BDI cases in our subgroup were detected after surgery, and one-third of patients used IOC. Compared to intermediate reconstruction (between 2 and 6 weeks postoperatively), early (<14 days) and delayed (>6 weeks) reconstruction following major BDI can reduce morbidity and the risk of anastomotic stricture, according to an even more recent systematic review and meta-analysis [5]. An immediate primary repair was only feasible in a small proportion of instances since the bulk of BDI in our group was discovered after surgery. Only 20–40% of BDIs often occur during the index case [7, 33]. The median interval between LC and BDI therapy in our population was seven days (range: 0–132 days). Our study's strength is that it examined a sizable single-center patient cohort that had LC utilizing a standardized surgical procedure, frequently carried out by young surgeons in a teaching hospital context, along with a long-term follow-up. This research's limitations include its retrospective design and its lengthy study duration, which make it challenging to derive reliable conclusions from even a thorough examination of this subgroup.

According to this study, a low incidence of BDI is linked to LC utilizing the standardized posterior infundibular approach. Despite having a relatively low prevalence, BDI has a significant negative impact on patients' quality of life and financial situation. Surgeons must be able to do LC in the safest manner possible by employing a dependable method that they are accustomed to and that can be applied in the majority of situations, even challenging LC involving significant inflammation or fibrosis.

1. Shang P, Liu B, Li X, Miao J, Lv R, Guo W. A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases. Acta Cirúrgica Brasileira. 2020 Jul 8;35(6):e202000607. 2. Booij KA, de Reuver PR, van Dieren S, van Delden OM, Rauws EA, Busch OR, van Gulik TM, Gouma DJ. Long-term impact of bile duct injury on morbidity, mortality, quality of life, and work related limitations. Annals of surgery. 2018 Jul 1;268(1):143-50. 3. Schreuder AM, Busch OR, Besselink MG, Ignatavicius P, Gulbinas A, Barauskas G, Gouma DJ, van Gulik TM. Long-term impact of iatrogenic bile duct injury. Digestive surgery. 2020 Jan 17;37(1):10-21. 4. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates J. Open cholecystectomy. A contemporary analysis of 42,474 patients. Annals of surgery. 1993 Aug;218(2):129. 5. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. Jama. 2003 Oct 22;290(16):2168-73. 6. Karvonen J, Gullichsen R, Laine S, Salminen P, Grönroos JM. Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution. Surgical endoscopy. 2007 Jul;21(7):1069-73. 7. Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ. Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surgical endoscopy. 2019 Mar 15;33(3):724-30. 8. Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker ME, Newman GE, Cotton PB, Meyers WC. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Annals of surgery. 1992 Mar;215(3):196. 9. Hugh TB. New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots. Surgery. 2002 Nov 1;132(5):826-35. 10. Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. Journal of hepato-biliary-pancreatic surgery. 2002 Nov;9(5):543-7. 11. Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. Journal of hepato-biliary-pancreatic surgery. 2002 Nov;9(5):543-7. 12. Strasberg SM, Eagon CJ, Drebin JA. The “hidden cystic duct” syndrome and the infundibular technique of laparoscopic cholecystectomy—the danger of the false infundibulum. Journal of the American College of Surgeons. 2000 Dec 1;191(6):661-7. 13. van de Graaf FW, Zaïmi I, Stassen LP, Lange JF. Safe laparoscopic cholecystectomy: a systematic review of bile duct injury prevention. International Journal of Surgery. 2018 Dec 1;60:164-72. 14. Iskandar M, Fingerhut A, Ferzli G. Posterior infundibular dissection: safety first in laparoscopic cholecystectomy. Surg Endosc 2021;35(6):3175–83 15. Strasberg SM, Brunt ML. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons. 2010 Jul 1;211(1):132-8. 16. Moore BJ, White S, Washington R, Coenen N, Elixhauser A. Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser Comorbidity Index. Medical care. 2017 Jul 1;55(7):698-705. 17. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240(2):205–13. 18. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. Journal of Gastrointestinal Surgery. 2009 Mar;13(3):498-503. 19. Pucher PH, Brunt LM, Fanelli RD, Asbun HJ, Aggarwal R. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surgical endoscopy. 2015 Nov;29(11):3074-85. 20. Iwashita Y, Hibi T, Ohyama T, Umezawa A, Takada T, Strasberg SM, Asbun HJ, Pitt HA, Han HS, Hwang TL, Suzuki K. Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul‐de‐sac or the birth pangs of a new technical framework?. Journal of Hepato‐Biliary‐Pancreatic Sciences. 2017 Nov;24(11):591-602. 21. Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, Fuks D, Giménez ME, Goumard C, Kaneko H, Memeo R. IRCAD recommendation on safe laparoscopic cholecystectomy. Journal of Hepato‐Biliary‐Pancreatic Sciences. 2017 Nov;24(11):603-15. 22. Wakabayashi G, Iwashita Y, Hibi T, Takada T, Strasberg SM, Asbun HJ, Endo I, Umezawa A, Asai K, Suzuki K, Mori Y. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). Journal of Hepato‐biliary‐pancreatic Sciences. 2018 Jan;25(1):73-86. 23. Brunt LM, Deziel DJ, Telem DA, Strasberg SM, Aggarwal R, Asbun H, Bonjer J, McDonald M, Alseidi A, Ujiki M, Riall TS. Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surgical endoscopy. 2020 Jul;34(7):2827-55. 24. Manatakis DK, Papageorgiou D, Antonopoulou MI, Stamos N, Agalianos C, Ivros N, Davides D, Pechlivanides G, Kyriazanos I. Ten-year audit of safe bail-out alternatives to the critical view of safety in laparoscopic cholecystectomy. World journal of surgery. 2019 Nov;43(11):2728-33. 25. Nijssen MA, Schreinemakers JM, Meyer Z, Van Der Schelling GP, Crolla RM, Rijken AM. Complications after laparoscopic cholecystectomy: a video evaluation study of whether the critical view of safety was reached. World journal of surgery. 2015 Jul;39(7):1798-803. 26. Daly SC, Deziel DJ, Li X, Thaqi M, Millikan KW, Myers JA, Bonomo S, Luu MB. Current practices in biliary surgery: do we practice what we teach?. Surgical endoscopy. 2016 Aug;30(8):3345-50. 27. Stefanidis D, Chintalapudi N, Anderson-Montoya B, Oommen B, Tobben D, Pimentel M. How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy?. Surgical endoscopy. 2017 Jan;31(1):142-6. 28. Strasberg SM, Brunt LM. The critical view of safety: why it is not the only method of ductal identification within the standard of care in laparoscopic cholecystectomy. Annals of surgery. 2017 Mar 1;265(3):464-5. 29. Francoeur JR, Wiseman K, Buczkowski AK, Chung SW, Scudamore CH. Surgeons’ anonymyous response after bile duct injury during cholecystectomy. Am J Surg 2003;185(5):468–75 30. Schwaitzberg SD, Scott DJ, Jones DB, McKinley SK, Castrillion J, Hunter TD, Michael Brunt L. Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed. Surgical endoscopy. 2014 Nov;28(11):3068-73. 31. Griffiths EA, Hodson J, Vohra RS, Marriott P, CholeS Study Group, Katbeh T, Zino S, Nassar AH, West Midlands Research Collaborative. Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy. Surgical endoscopy. 2019 Jan 15;33(1):110-21. 32. Alvarez FA, De Santibañes M, Palavecino M, Sánchez Clariá R, Mazza O, Arbues G, de Santibañes E, Pekolj J. Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury. Journal of British Surgery. 2014 May;101(6):677-84. 33. Rystedt JM, Kleeff J, Salvia R, Besselink MG, Prasad R, Lesurtel M, Sturesson C, Hilal MA, Aljaiuossi A, Antonucci A, Ardito F. Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy–an E-AHPBA multi-center study. Hpb. 2019 Dec 1;21(12):1641-7.