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Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.

Dekker, Sidney LU and Hugh, Thomas B (2008) In ANZ Journal of Surgery 78(12). p.1109-1114
Abstract
Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was... (More)
Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision-making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception ('seeing what you believe') were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the 'culture' of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply 'stopping rules' for modifying or converting the operation. (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
intraoperative complication, bile duct, laparoscopic, cholecystectomy
in
ANZ Journal of Surgery
volume
78
issue
12
pages
1109 - 1114
publisher
Wiley-Blackwell
external identifiers
  • wos:000261515700014
  • scopus:57349119454
  • pmid:19087053
ISSN
1445-2197
DOI
10.1111/j.1445-2197.2008.04761.x
language
English
LU publication?
yes
id
33ba4762-d6d4-4965-9e18-d9785518bde8 (old id 1305789)
date added to LUP
2009-01-16 08:54:19
date last changed
2017-05-07 03:51:13
@article{33ba4762-d6d4-4965-9e18-d9785518bde8,
  abstract     = {Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision-making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception ('seeing what you believe') were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the 'culture' of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply 'stopping rules' for modifying or converting the operation.},
  author       = {Dekker, Sidney and Hugh, Thomas B},
  issn         = {1445-2197},
  keyword      = {intraoperative complication,bile duct,laparoscopic,cholecystectomy},
  language     = {eng},
  number       = {12},
  pages        = {1109--1114},
  publisher    = {Wiley-Blackwell},
  series       = {ANZ Journal of Surgery},
  title        = {Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.},
  url          = {http://dx.doi.org/10.1111/j.1445-2197.2008.04761.x},
  volume       = {78},
  year         = {2008},
}