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Perceptual Errors Leading to Bile Duct Injury During Laparoscopic Cholecystectomy

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Management of Benign Biliary Stenosis and Injury

Abstract

Application of human factors concepts to high-risk activities has facilitated reduction in human error. With introduction of laparoscopic cholecystectomy, the incidence of major bile duct injury increased. Most injuries involved deliberate major bile duct transection due to misperception of the anatomy. This illusion is sufficiently compelling such that the surgeon usually does not recognize it. We elucidate our experience in the analysis of over 300 laparoscopic bile duct injuries within the framework of human error analysis and normal human perception. The primary cause of error was a visual perceptual illusion; the neurocognitive aspects of normal visual and haptic perception are discussed as well as alterations in this perception within the laparoscopic environment. Surgical sensemaking and situation awareness is also discussed, as well as factors that led to injury detection, including the use of framing. Since the complication-causing error occurred at few key steps during laparoscopic cholecystectomy, we have formulated specific rules to decrease the incidence of bile duct injury. This analysis provides insights into the complexity of surgical perception and human error

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References

  1. Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165:9–14.

    Article  PubMed  CAS  Google Scholar 

  2. Vecchio R, MacFadyen BV, Latteri S. Laparoscopic cholecystectomy: an analysis on 114,005 cases of United States series. Int Surg. 1998;83:215–9.

    PubMed  CAS  Google Scholar 

  3. Adamsen S, Hansen OH, Funch-Jensen P, Schultze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg. 1997;184:571–8.

    PubMed  CAS  Google Scholar 

  4. Nuzzo G, Giuliante F, Giovannini I, Ardito F, D’Acapito F, Vellone M, Murazio M, Capelli G. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56591 cholecystectomies. Arch Surg. 2005;140:986–92.

    Article  PubMed  Google Scholar 

  5. Harboe KM, Bardram L. The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. Surg Endosc. 2011;25:1630–41.

    Article  PubMed  Google Scholar 

  6. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324:1073–8.

    Article  Google Scholar 

  7. Francoeur JR, Wiseman K, Buczkowski AK, Chung SW, Scudamore CH. Surgeons’ anonymous response after bile duct injury during cholecystectomy. Am J Surg. 2003;185:468–75.

    Article  PubMed  Google Scholar 

  8. Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention of laparoscopic bile duct injuries: an analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237:460–9.

    PubMed  PubMed Central  Google Scholar 

  9. Stewart L. Iatrogenic biliary injuries: identification, classification, and management. Surg Clin North Am. 2014;94:297–310.

    Article  PubMed  Google Scholar 

  10. Stewart L, Dominguez CO, Way LW. A data-frame sensemaking analysis of operative reports. In: Mosier KL, Fischer UM, editors. Informed by knowledge: expert performance in complex situations. New York, NY: Taylor and Francis; 2011. p. 329–38.

    Google Scholar 

  11. Stewart L, Way LW, The Prevention of Laparoscopic Bile Duct Injuries: an Analysis of 300 Cases of from a Human Factors and Cognitive Psychology Perspective. Proc Hum Fact Ergon Soc, 2007 http://pro.sagepub.com/cgi/secure_ppv

  12. Stewart L, Hunter JG, Wetter A, Chin B, Way LW. Operative reports: form and function. Arch Surg. 2010;145:865–71.

    Article  PubMed  Google Scholar 

  13. Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg. 1995;130:1123–9.

    Article  PubMed  CAS  Google Scholar 

  14. Stewart L. Treatment strategies for bile duct injury and benign biliary stricture. In: Poston G, Blumgart L, editors. Hepatobiliary and pancreatic surgery. 1st ed. London: Martin Dunitz; 2002. p. 315–29.

    Google Scholar 

  15. Stewart L, Robinson TN, Lee CM, Liu K, Whang K, Way LW. Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences. J Gastrointest Surg. 2004;8:523–31.

    Article  PubMed  Google Scholar 

  16. Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg. 1999;229:449–57.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  17. Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543–7.

    Article  PubMed  Google Scholar 

  18. Strasberg SM. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg. 2008;15:284–92.

    Article  PubMed  Google Scholar 

  19. Machi J, Johnson JO, Deziel DJ, Soper NJ, Berber E, Siperstein A, Hata M, Patel A, Singh K, Arregui ME. The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study. Surg Endosc. 2009;23:384–8.

    Article  PubMed  Google Scholar 

  20. Lillemoe KD. Current management of bile duct injury. Br J Surg. 2008;95:403–5.

    Article  PubMed  CAS  Google Scholar 

  21. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery. 2002;132:826–35.

    Article  PubMed  Google Scholar 

  22. Strasberg SM, Gouma DJ. ‘Extreme’ vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB (Oxford). 2012;14:1–8.

    Article  Google Scholar 

  23. Navez B, Ungureanu F, Michiels M, Claeys D, Muysoms F, Hubert C, Vanderveken M, Detry O, Detroz B, Closset J, Devos B, Kint M, Navez J, Zech F, Gigot JF, The Belgian Group for Endoscopic Surgery (BGES) and the Hepatobiliary and Pancreatic Section (HBPS) of the Royal Belgian Society of Surgery. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg Endosc. 2012;26(9):2436–45.

    Article  PubMed  Google Scholar 

  24. Söderlund C, Frozanpor F, Linder S. Bile duct injuries at laparoscopic cholecystectomy: a single-institution prospective study. Acute cholecystitis indicates an increased risk. World J Surg. 2005;29:987–93.

    Article  PubMed  Google Scholar 

  25. Georgiades CP, Mavromatis TN, Kourlaba GC, Kapiris SA, Bairamides EG, Spyrou AM, Kokkinos CN, Spyratou CS, Ieronymou MI, Diamantopoulos GI. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy? Surg Endosc. 2008;22:1959–64.

    Article  PubMed  Google Scholar 

  26. Schwaitzberg SD, Scott DJ, Jones DB, McKinley SK, Castrillion J, Hunter TD, Brunt LM. 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. Surg Endosc. 2014;28:3068–73.

    Article  PubMed  Google Scholar 

  27. Massarweh NN, Devlin A, Symons RG, Elrod JB, Flum DR. Risk tolerance and bile duct injury: surgeon characteristics, risk-taking preference, and common bile duct injuries. J Am Coll Surg. 2009;209:17–24.

    Article  PubMed  Google Scholar 

  28. Fischer JE. Is damage to the common bile duct during laparoscopic cholecystectomy an inherent risk of the operation? Am J Surg. 2009;197:829–32.

    Article  PubMed  Google Scholar 

  29. Hoffman DD. Visual intelligence. How we create what we see. New York, NY: WW Norton & Co; 1998.

    Google Scholar 

  30. Hoffman DD. The construction of visual reality. In: Blom JD, Sommer IEC, editors. Hallucinations. Research and Practice. New York, NY: Springer; 2012. p. 7–16.

    Chapter  Google Scholar 

  31. Palmer SE. Vision science. Photons to phenomenology. Cambridge, MA: MIT Press; 1999.

    Google Scholar 

  32. Proffitt DR. Embodied perception and the economy of action. Perspect Psychol Sci. 2006;1:110–22.

    Article  PubMed  Google Scholar 

  33. Proffitt DR, Linkenauger SA. Perception viewed as a phenotypic expression. In: Prinz W, Beisert M, Herwig A, editors. Action science: foundations of an emerging discipline. Cambridge: MIT Press; 2013. p. 171–98.

    Chapter  Google Scholar 

  34. Martinez-Conde S, Macknik SL, Hubel DH. The role of fixational eye movements in visual perception. Nat Rev Neurosci. 2004;5:229–40.

    Article  PubMed  CAS  Google Scholar 

  35. Brockmole JR, Irwin DE. Eye movements and the integration of visual memory and visual perception. Percept Psychophys. 2005;67:495–512.

    Article  PubMed  Google Scholar 

  36. Melcher D, Marrone MC. Spatiotopic temporal integration of visual motion across saccadic eye movements. Nat Neurosci. 2003;6:877–81.

    Article  PubMed  CAS  Google Scholar 

  37. Burr DC, Santoro L. Temporal integration of optic flow, measured by contrast and coherence thresholds. Vision Res. 2001;41:1891–9.

    Article  PubMed  CAS  Google Scholar 

  38. Noe A, editor. Is the visual world a grand illusion? Charlottesville, VA: Imprint Academic; 2002.

    Google Scholar 

  39. Hoffman DD. The interface theory of perception: natural selection drives true perception to swift extinction. In: Dickinson S, Tarr M, Leonardis A, Schiele B, editors. Object categorization: computer and human vision perspectives. Cambridge, UK: Cambridge University Press; 2009. p. 148–65.

    Chapter  Google Scholar 

  40. Mark JT, Marion BB, Hoffman DD. Natural selection and veridical perceptions. J Theor Biol. 2010;266:504–15.

    Article  PubMed  Google Scholar 

  41. El Saddik A, Orozco M, Eid M, Cha J. Haptics technologies, springer series on touch and haptic systems. Berlin Heidelberg: Springer-Verlag; 2011.

    Google Scholar 

  42. Kitada R, Johnsrude I, Kochiyama T, Lederman SJ. Functional specialization and convergence in the occipito-temporal cortex supporting haptic and visual identification of human faces and body parts: An fMRI study. J Cogn Neurosci. 2009;21:1–19.

    Article  Google Scholar 

  43. Costantini M, Urgesi C, Galati G, Romani GL, Aglioti SM. Haptic perception and body representation in lateral and medial occipito-temporal cortices. Neuropsychologia. 2011;49:821–9.

    Article  PubMed  Google Scholar 

  44. James TW, Humphrey GK, Gati JS, Servos P, Menon RS, Goodale MA. Haptic study of three-dimensional objects activates extrastriate visual areas. Neuropsychologia. 2002;10:1706–14.

    Article  Google Scholar 

  45. Kitada R, Ingrid S, Johnsrude IS, Kochiyama T, Lederman SJ. Brain networks involved in haptic and visual identification of facial expressions of emotion: An fMRI study. Neuroimage. 2010;49:1677–89.

    Article  PubMed  Google Scholar 

  46. Sathian K. Visual cortical activity during tactile perception in the sighted and the visually deprived. Dev Psychobiol. 2005;46:279–86.

    Article  PubMed  CAS  Google Scholar 

  47. Lederman SJ, Klatzky RL. Relative availability of surface and object properties during early haptic processing. J Exp Psychol Hum Percept Perform. 1997;23:1680–707.

    Article  PubMed  CAS  Google Scholar 

  48. Klatzky RL, Lederman SJ, Matula DE. Imagined haptic exploration in judgments of object properties. J Exp Psychol Learn Mem Cogn. 1991;17:314–22.

    Article  PubMed  CAS  Google Scholar 

  49. Klatzky RL, Lederman SJ, Matula DE. Haptic exploration in the presence of vision. J Exp Psychol Hum Percept Perform. 1993;19:726–43.

    Article  PubMed  CAS  Google Scholar 

  50. Proffitt DR, Bhalla M, Gossweiler R, Midgett J. Perceiving geographical slant. Psychon Bull Rev. 1995;2:409–28.

    Article  PubMed  CAS  Google Scholar 

  51. Ernst MO, Banks MS, Bülthoff HH. Touch can change visual slant perception. Nat Neurosci. 2000;3:69–73.

    Article  PubMed  CAS  Google Scholar 

  52. Atkins JE, Fiser J, Jacobs RA. Experience-dependent visual cue integration based on consistencies between visual and haptic percepts. Vision Res. 2001;41:449–61.

    Article  PubMed  CAS  Google Scholar 

  53. Atkins JE, Jacobs RA, Knill DC. Experience-dependent visual cue recalibration based on discrepancies between visual and haptic percepts. Vision Res. 2003;43:2603–13.

    Article  PubMed  Google Scholar 

  54. Jacobs RA. What determines visual cue reliability? Trends Cogn Sci. 2002;6:345–50.

    Article  PubMed  Google Scholar 

  55. Ho YX, Serwe SM, Trommershauser J, Maloney LT, Landy MS. The role of visuohaptic experience in visually perceived depth. J Neurophysiol. 2009;101:2789–801.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Lalanne C, Lorenceau J. Crossmodal integration for perception and action. J Physiol Paris. 2004;98:265–79.

    Article  PubMed  Google Scholar 

  57. Proffitt DR, Stefanucci J, Banton T, Epstein W. The role of effort in distance perception. Psychol Sci. 2003;14:106–12.

    Article  PubMed  Google Scholar 

  58. Linkenauger SA, Witt JK, Proffitt DR. Taking a hands on approach: apparent grasping ability scales the perception of object size. J Exp Psychol Hum Percept Perform. 2011;37:1432–41.

    Article  PubMed  Google Scholar 

  59. Witt JK, Proffitt DR. Action-specific influences on distance perception: a role for motor simulation. J Exp Psychol Hum Percept Perform. 2008;34:1479–92.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Coello Y, Delevoye-Turrell Y. Embodiment, spatial categorization and action. Conscious Cogn. 2007;16:667–83.

    Article  PubMed  Google Scholar 

  61. Shiffrar M, Heinen T. Athletic ability changes action perception: Embodiment in the visual perception of human movement. Zeitschrift fur Sportpsychologie (German J Sport Psychol). 2011;17(4):1–13 [English].

    Google Scholar 

  62. Wilson M, Knoblich G. The case for motor involvement in perceiving conspecifics. Psychol Bull. 2005;131:460–73.

    Article  PubMed  Google Scholar 

  63. Morgado N, Gentaz É, Guinet É, Osiurak F, Palluel-Germain R. Within reach but not so reachable: Obstacles matter in visual perception of distances. Psychon Bull Rev. 2013;20:462–7.

    Article  PubMed  Google Scholar 

  64. Hein A, Diamond RM. Locomotory space as a prerequisite for acquiring visually guided reaching in kittens. J Comp Physiol Psychol. 1972;81:394–8.

    Article  PubMed  CAS  Google Scholar 

  65. Held R, Hein A. Movement-produced stimulation in the development of visually guided behavior. J Comp Physiol Psychol. 1963;56:872–6.

    Article  PubMed  CAS  Google Scholar 

  66. Corbetta D, Thurman SL, Wiener RF, Guan Y, Williams JL. Mapping the feel of the arm with the sight of the object: on the embodied origins of infant reaching. Front Psychol. 2014;5:576–93.

    PubMed  PubMed Central  Google Scholar 

  67. Beilock SL. Beyond the playing field: sport psychology meets embodied cognition. Int Rev Sport Exerc Psychol. 2008;1:19–30.

    Article  Google Scholar 

  68. Zsambok CE, Klein GA, editors. Naturalistic decision making. Mahwah, NJ: Lawrence Erlbaum Associates; 1997.

    Google Scholar 

  69. Klein G. Sources of power: how people make decisions. Cambridge, MA: MIT Press; 1998.

    Google Scholar 

  70. Klein G. The power of intuition: how to use your gut feelings to make better decisions at work. New York, NY: Random House; 2004.

    Google Scholar 

  71. Snowden D, Klein G, Chew LP, Teh CA, A sensemaking experiment: Techniques to achieve cognitive precision. In Proceedings of the 12th International Command and Control Research and Technology Symposium, Newport, RI. 2007, www.dodcarp.org

  72. Endsley MR, Garland DJ. Situation awareness analysis and measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 2000.

    Google Scholar 

  73. Wickens CD. Situation awareness: review of mica Endsley’s 1995 articles on situation awareness theory and measurement. Hum Factors. 2008;50:397–403.

    Article  PubMed  Google Scholar 

  74. Dominguez CO. Expertise in laparoscopic surgery: anticipation and affordances. In: Salas E, Klein G, editors. Linking expertise and naturalistic decision making. Mahwah, NJ: Lawrence Erlbaum & Associates; 2001. p. 287–302.

    Google Scholar 

  75. Klein G, Moon B, Hoffman RR, Making sense of sensemaking 1: alternative perspectives. IEEE Intelligent Systems, 2306; 21(4): 70-73

    Google Scholar 

  76. Klein G, Moon B, Hoffman RR. Making sense of sensemaking 2: A macrocognitive model. IEEE Intel Syst. 2006;21(5):88–92.

    Article  Google Scholar 

  77. Reason J. Human error. Cambridge, UK: Cambridge University Press; 1990.

    Book  Google Scholar 

  78. Krems JF, Zierer C. Are experts immune to cognitive bias? Dependence of “confirmation bias” on specialist knowledge. Z Exp Angew Psychol. 1994;41:98–115. German.

    PubMed  CAS  Google Scholar 

  79. Rudolph JW. Into the big muddy and out again: Error persistence and crisis management in the operating room. 2004 PhD Thesis, Retrieved from http://search.proquest.com/docview/620617113?accountid=14525

  80. Friedman RS, Förster J. Implicit affective cues and attentional tuning: an integrative review. Psychol Bull. 2010;136:875–93.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Borst JP, Taatgen NA, Van Rijn H. The problem state: a cognitive bottleneck in multitasking. J Exp Psychol Learn Mem Cogn. 2010;36:363–82.

    Article  PubMed  Google Scholar 

  82. McElree B. Working memory and focal attention. J Exp Psychol Learn Mem Cogn. 2001;27:817–35.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  83. Baddeley A. Working memory: theories, models, and controversies. Annu Rev Psychol. 2012;63:1–29.

    Article  PubMed  Google Scholar 

  84. Lavie N. Attention, distraction, and cognitive control under load. Curr Dir Psychol Sci. 2010;19:143–8.

    Article  Google Scholar 

  85. Rees G, Lavie N. What can functional imaging reveal about the role of attention in visual awareness? Neuropsychologia. 2001;39:1343–53.

    Article  PubMed  CAS  Google Scholar 

  86. Woods DD, Johannesen LJ, Cook RI. State-of-the-Art Report, Behind Human Error: Cognitive Systems, Computers, and Hindsight. Crew System Ergonomics Information Analysis Center (CSERIAC) SOAR, Series Editor: Aaron W. Schopper PhD. 1994, http://www.dtic.mil/dtic/tr/fulltext/u2/a492127.pdf

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Authors and Affiliations

  1. Department of Surgery, University of Califronia, San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA

    Lygia Stewart M.D.

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  1. Lygia Stewart M.D.
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Correspondence to Lygia Stewart M.D. .

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Editors and Affiliations

  1. Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada

    Elijah Dixon

  2. Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Charles M. Vollmer Jr.

  3. Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada

    Gary R. May

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Stewart, L. (2015). Perceptual Errors Leading to Bile Duct Injury During Laparoscopic Cholecystectomy. In: Dixon, E., Vollmer Jr., C., May, G. (eds) Management of Benign Biliary Stenosis and Injury. Springer, Cham. https://doi.org/10.1007/978-3-319-22273-8_14

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  • DOI: https://doi.org/10.1007/978-3-319-22273-8_14

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