Biliary Injury in Laparoscopic Surgery:
Part 2. Changing the Culture of Cholecystectomy
Steven M Strasberg, MD, FACS
This article simultaneously discusses prevention of bili-
ary injury and reduction of the possibility of litigation
arising from nonnegligent injury. These are considered
together during the three periods of encounter with a
patient having cholecystectomy: preoperative, operative,
and postoperative. The goals of this article are preven-
tion of biliary injury and institution of a practice ap-
proach that will make it apparent when injury is not
from negligence. Plaintiffs’ attorneys are guided, under-
standably, by the aphorism “Where there’s smoke there’s
fire,” and patients may seek out attorneys when care
seems deficient even when it is not. Costly, time-
consuming legal actions, as a result, may be initiated to
discover evidence that might have been placed in the
chart in the first instance. Improving the current prob-
lem of steeply spiraling costs of malpractice insurance
through actions of those outside the profession, such as
legislatures, is a worthy goal. But to pursue only that
strategy is akin to asking for a good police department in
a community, but having faulty locks at home. It is my
opinion that we, as surgeons, can have great impact on
malpractice litigation in this area by focusing on our
own actions. The following are suggestions for what I
consider “good practice.” These are within the standard
of care, but they do not purport to represent the stan-
dard of care in the sense that they exclude other ap-
proaches from also being appropriate. General issues
such as evaluation of patients suitable for surgery based
on comorbidities are omitted.
Preoperative care
The initial visit is used to make the diagnosis, to deter-
mine whether the patient is a candidate for laparoscopic
cholecystectomy, and to obtain consent for the proce-
dure, even though the actual consent form may not be
signed at that time.
Competing Interests Declared: None.
Received March 11, 2005; Accepted April 4, 2005.
From the Section of Hepatobiliary-Pancreatic and Gastrointestinal Surgery,
Department of Surgery, Washington University in St Louis, St Louis, MO.
Correspondence address: Steven M Strasberg, MD, Box 8109, Suite 17308
Queeny Tower, 1 Barnes Hospital Plaza, St Louis, MO 63110.
© 2005 by the American College of Surgeons
Published by Elsevier Inc.
Indication for cholecystectomy
The indication for surgery should be clearly docu-
mented in the record and summarized by the surgeon in
a consultation letter, or in an admission note. In a biliary
injury patient, the presence of a questionable indication
for operation (often simply a lack of documentation)
will reflect on the overall care that the patient received
(eg, “The bile duct was damaged in an operation that
was not indicated”). The most common indication for
cholecystectomy is symptomatic cholelithiasis, and the el-
ements of diagnosis are straightforward — biliary colic and
demonstration of stones by medical imaging. So it is desir-
able to document the characteristics of the pain and the
results of imaging. When less common indications such as
biliary dyskinesia or noncalculous gallbladder pathology
are the reason for recommending cholecystectomy, the
symptoms and the objective evidence linking the symp-
toms to the gallbladder are the elements to be recorded.
Consent
The purpose of the consent procedure is to permit the
patient to make an autonomous decision about surgery.
Autonomy means that the patient has reached the deci-
sion to undergo an operation on his own, after being
informed reasonably completely about the benefits and
risks of the procedure. Important outcomes of taking the
time to provide this type of consent are a good under-
standing of what to expect on the part of the patient and
usually, the patient’s family. An unexpected negative
event is probably the single most common occurrence
triggering litigation, because it causes resentment and
often results in loss of confidence in the surgeon. Con-
versely, when negative outcomes occurs to a patient who
has been properly prepared for their possibility, it is
much less likely to initiate litigation. Like autonomy,
expectation is a key word in the avoidance of litigation.
Four items of information needed by a patient to
make the autonomous judgment are:
1. The rationale for the procedure: how was the diagnosis arrived
at and how does cholecystectomy relieve symptoms and pre-
vent later consequences of cholelithiasis.
2. Description of the procedure: what is actually done by the
ISSN 1072-7515/05/$30.00
604 doi:10.1016/j.jamcollsurg.2005.04.032
Vol. 201, No. 4, October 2005
surgeon and what the patient will experience from the
start of preparation for the operation until full recovery.
3. The risks of the procedure by type, incidence severity, and
consequences.
4. The alternatives to the proposed treatment.
The procedure should be explained in plain terms and
from a patient’s perspective. Details such as the degree of
postoperative pain and how pain will be managed, when
oral intake will be stopped and resumed, and when nor-
mal activity and work will be possible are important to
patients. Risk of complications should be described in
realistic terms with approximate but accurate data. Rea-
sons for conversion to open cholecystectomy should be
discussed and the role of conversion as a safety measure
emphasized. When there is an increased chance of con-
version, as in patients with acute cholecystitis,1 the in-
creased possibility of conversion should be made clear.
In providing information for consent, the surgeon is the
patient’s teacher and like a good teacher, should confirm
that the patient understands what has been said and
knows what to expect. Whenever possible, explanations
should be given in front of close family members, typi-
cally a spouse, and should be followed by the surgeon
initiating an opportunity to ask questions (“Did you
understand everything and are there any questions that
you would like to ask?”). Brochures designed to explain
the procedure and its risks are very helpful and their use
is encouraged. But they do not replace the need for the
surgeon to discuss the procedure with the patient.
Patients, some of whom are medically naïve, are often
provided with many facts by several different individuals
(family doctor, surgeon, nurses, and others) at the time
they present with symptomatic cholelithiasis. Not sur-
prisingly, many do not remember they were told preop-
eratively that occasionally, perhaps because of local con-
ditions, such as inflammation and anatomic variation,
biliary injury unavoidably occurs during cholecystec-
tomy. Unquestionably, litigation may be initiated not
because there was actual negligence during performance
of a procedure in which biliary injury occurred, but be-
cause the patient and family were not informed in such a
way that they retained the information that allowed
them to know what to expect.
Documentation of the explanations leading to con-
sent is mandatory. Negligence in obtaining consent is
usually not the key issue in litigation, but it may be a
complicating issue. Failure of clear documentation of
Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 605
the consent procedure may appear as “smoke,” ie, poor
practice suggesting other poor practice to a lawyer inves-
tigating a case. If members of a jury believe that the
standard of care was breached in obtaining consent, they
are probably more likely to conclude that it was also
breached elsewhere. Good documentation is important
because without it, the patient’s claim of not being in-
formed usually will take precedence over the surgeon’s
claim that proper information was given, even when the
same consent is always provided by the surgeon, ie, that
it is custom and habit to do so.
Documentation that the risk of complications and spe-
cifically biliary injury have been discussed with the patient
may be recorded in the letter of consultation in the opera-
tive note or elsewhere. Although this is acceptable, it is my
opinion, given the frequency of litigation arising from lapa-
roscopic cholecystectomy, that a new approach should be
adopted: the use of a checklist. Checklists are common
safety measures in many industries including aviation. An
example is shown in Figure 1. It is suggested that a checklist
be used as a guide in the consent discussion for patients
being prepared for cholecystectomy and that the checklist
then be shown or given to the patient, with an opportunity
to discuss items on the list. Such an approach will not be
forgotten by the patient and the list provides proof that the
consent was obtained in an exemplary manner. The check-
list shown in the table goes into moderate detail. A checklist
could be as simple as the four key points in consent listed
previously and bolded in Figure 1, or as detailed as the
information provided in some patient information sites.2,3
In addition, the American College of Surgeons has recently
sponsored a publication about avoidance of litigation that
contains other useful information about the importance of
interpersonal relationships.4
The operation
Identification of the cystic structures
The main cause of biliary injury, as noted in the companion
article, is misidentification of the common bile duct, the
common hepatic duct, or an aberrant duct (usually on the
right) as the cystic duct. So the goal of dissection in chole-
cystectomy is the conclusive identification of the cystic
structures. The surgeon has an obligation to use a method
whose purpose is to obtain conclusive identification of the
cystic duct (and artery), although as indicated in the com-
panion article,5 the method may not always succeed. I
know of four such methods in current use: cholangiogra-
phy, the critical view technique, the infundibular tech-
606 Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 J Am Coll Surg

Figure 1. Model laparoscopic cholecystectomy consent checklist.

Vol. 201, No. 4, October 2005
Figure 2. The deception of the hidden cystic duct and the infundib-
ular technique of laparoscopic cholecystectomy. Left: Appearance
to surgeon when a duct appearing to be the cystic duct is dissected
first. Note that the duct appears to flare (heavy black line), giving the
appearance that the cystic duct has been followed onto the infun-
dibulum. Right: True anatomic situation in some cases of classic
injuries. The deceptive flaring appearance (heavy black line) is
caused by the separation of the cystic and common hepatic ducts or
the side of the common hepatic duct and the side of the gallbladder.
Note that such a deception is much less likely if the dissection is
carried to the “critical view” before dividing any structure. CBD,
common bile duct; CHD, common hepatic duct. (From: Strasberg
SM, Eagon CJ, Drebin JA. The “hidden cystic duct” syndrome and
the infundibular technique of laparoscopic cholecystectomy—the
danger of the false infundibulum. J Am Coll Surg 2000;191:661–
667, with permission).
nique, and dissection of main bile ducts so that the com-
mon bile duct, common hepatic duct, and cystic duct are
identified at the point that they unite. All of these methods
are within current practice norms. One of these methods
should be used, although in my opinion, the third and
fourth methods have considerable disadvantages.
The problems with the infundibular technique have
been discussed in a previous publication.6 It seems that
the infundibular technique is prone to failure in the
presence of severe acute or chronic inflammation and
when the cystic duct is hidden or effaced by a large stone,
or hidden because of difficulty in retracting the gallblad-
der (Fig. 2). Stated in the language of human error anal-
ysis,7 we consider the infundibular technique to be a
well-intentioned workaround, introduced to permit
cholecystectomies to be done laparoscopically, a
method, which, however, has actually turned out to be
“an error trap”7 for competent surgeons.
Identification by dissection of the main bile ducts
laparoscopically as a routine should probably be discour-
aged because of the increased possibility of injury to the
main bile ducts during dissection. Also, in the 25% of
patients who have parallel or spiral union of the cystic
Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 607
duct with the common bile duct, identification will be
hard because it is difficult to see the exact point of union
of the cystic duct with the common duct. The parallel
union was recognized as a potential danger even in the
era of open cholecystectomy.8
Cholangiography is a good means of ductal identifi-
cation, and routine cholangiography reduces biliary in-
juries,9,10 but will only succeed if the cholangiogram is
interpreted correctly. Unfortunately, ductal injuries have
occurred in the face of clear cholangiographic abnormal-
ities that should have alerted the surgeon to danger.11,12
These abnormalities often involve interpretation of the
anatomy of the upper bile ducts. For instance, the failure
to see any bile ducts above the insertion of what was
believed to be the cystic duct should be taken to mean
that actually the common bile duct rather than the cystic
duct has been cannulated, until proved otherwise. Up-
per bile ducts should show a normal branching pattern,
with ducts going to the right and left. Also, it is not
acceptable to rely on a cholangiogram in which impor-
tant details are obscured by leakage of dye. Cholangio-
grams may be repeated, but in the case of persistent
doubt, an open exploration is desirable. A particular
“system” problem with cholangiography relates to aber-
rant right ducts and is illustrated in Figure 3. Figure 3A
shows a postoperative ERCP in which an aberrant duct
has been preserved by dissection at a earlier laparoscopic
cholecystectomy. Figures 3B and 3C are reconstructions
of Figure 3A that show what a cholangiogram would
look like if aberrant ducts of various types were mistak-
enly cannulated under the impression they were the cys-
tic duct. We have seen a number of aberrant duct injuries
with apparently “normal” cholangiograms, as in Figure
3B. The “critical view” method13 is my preferred tech-
nique, but it is somewhat more difficult because it re-
quires a more complete dissection of the triangle of
Calot and additional dissection time. Whichever
method is used, the surgeon should not clip or divide
“cystic” structures (either duct or artery) until he or she
is convinced that one of these methods of ductal identi-
fication has been applied to its end point.
Changing the culture of cholecystectomy:
“stopping rules,” conversion to open
cholecystectomy, and performance
of cholecystostomy
In many industries there are stopping rules. These rules
are applied in the face of dangerous conditions and are
intended to stop a process before it continues into a zone
608 Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 J Am Coll Surg

Figure 3. (A) ERCP showing aberrant right hepatic duct which has been preserved during a earlier laparoscopic cholecystectomy. The clips
beside the duct show that the cystic duct entered the aberrant duct. The aberrant duct is the duct from segment 5. (B) Reconstruction of the
image to show what a cholangiogram would look like if the aberrant duct had been cannulated. Very few surgeons would recognize that one
segmental duct was missing on the right side and an injury to the aberrant duct would probably follow. (C) Reconstruction of the image to show
what a cholangiogram would look like if the aberrant duct was actually the right main bile duct. Note the much more obvious cholangiographic
abnormality of total absence of right hepatic ducts. Arrow points to left hepatic duct.

of great risk. Good examples exist in aviation. If a flight
is diverted to a secondary airport, it may be that the
“ceiling” was too low at the primary airport. The process
in making this decision is instructive. When the altime-
ter is at a specific value, the pilot must be able to see the
runway clearly. If the runway cannot be seen the landing
must be aborted. There is no leeway in this decision, no
descending another 20 or 30 feet to take a peek. It is a
hard and fast stopping rule for certain types of aircraft.
The negative effects of diversion to a secondary airport
are considered to be minor compared with the risk of a
dangerous landing and its possible disastrous conse-
quences. Note that the principle here is not merely
avoidance of a crash. It is avoidance of entry into a dan-
ger zone in which the probability of a crash begins to rise
to an unacceptable level. In a nuclear reactor, the core
temperature is closely monitored and there are inviolate
stopping rules that shut down the reactor when certain
parameters are exceeded. Again, the principle is to halt
before a zone of great danger is entered.
The application of a stopping rule to cholecystectomy
for cholelithiasis is not as simple as that for a mechanical
device such as an airplane or a nuclear power plant. The
human body is much more complex than these mechan-
ical systems; there are no “pop ups” on the video monitor
during a laparoscopic cholecystectomy that signal the
need to convert to open cholecystectomy. But what is
important is the adoption of the mindset of the stopping
rule in which safety is the chief consideration that gov-
erns decisions when danger is apparent. This is especially
appropriate in a benign disease such as cholelithiasis,
particularly because there are alternatives to pushing
ahead with a difficult dissection.
When operative difficulty is encountered during lapa-
roscopic cholecystectomy, the surgeon should pause to
determine whether the operation should be continued
laparoscopically. Local operative factors and operative
experience of the surgeon are key considerations. Failure
of progression of the dissection, anatomic disorienta-
tion, difficulty in visualization of the field, and inability
of the laparoscopic equipment to carry out usual tasks
such as grasping of the gallbladder or separation of tis-
sues, are events that might be used as triggers of the
stopping rule mentality in which subsequent actions are
governed chiefly by considerations of safety. In most
cases these events are indicators for conversion (or con-
sultation). The negative effects of conversion are minor
compared with the negative effect of a biliary injury, so
like the airplane landing, it is best to back off when the
zone of serious danger is entered rather than to deter-
Vol. 201, No. 4, October 2005
mine if the procedure can be completed under danger-
ous conditions. The stopping rule mentality should not
end after an incision has been made and applies equally
to the difficult open cholecystectomy, in which the risk
of completing an open cholecystectomy must be bal-
anced against the risk of injury. Cholecystostomy is a
good alternative in very difficult patients, and it is al-
most always possible. Partial cholecystectomy is another
reasonable alternative in some cases of difficult open
cholecystectomy.14 The worst injuries we have seen have
come after conversion in patients with severe inflamma-
tion and have involved major vascular injuries and inju-
ries to the bile ducts. Although the airplane analogies are
useful, they can be taken only so far. Because of variation
in operative experience, what constitutes the zone of
serious danger may differ somewhat among surgeons.
In my opinion, the points made in the previous para-
graphs cannot be emphasized too strongly and should be
ingrained in all trainees, even though today these are in
the “ought to be” category that will require a change in
culture to achieve. There is an outlet when laparoscopic
cholecystectomy is very difficult and potentially hazard-
ous: conversion. There is an outlet when open cholecys-
tectomy is very difficult and potentially hazardous: cho-
lecystostomy. It is not appropriate to proceed
laparoscopically when conditions are patently hazard-
ous. For instance, it is inappropriate to attempt to stop
bleeding laparoscopically when one cannot see well and
there is a possibility that application of clips might also
clip and injure bile ducts. In addition, the presence of
clips on such a structure after operation, when it has
been described that they have been used to arrest hem-
orrhage (and when other local operative conditions fall
into the expected range for this procedure), is likely to
convince most experts that the action was practice below
the standard of care. The mind set of surgical trainees
should be directed to methods that result in completing
a large number of cholecystectomies safely, even if that
means that fewer cholecystectomies are completed lapa-
roscopically and that more converted laparoscopic pro-
cedures are completed by cholecystostomy.
Misidentification is not the only cause of biliary in-
jury. Technical causes such as cautery burns to ducts,
slippage of clips that have been applied to ducts, entry
into a bile duct in the gallbladder bed, and tenting of the
common bile duct while applying clips, can result in
biliary injury. Injury might also complicate bile duct
exploration. A complete discussion of avoidance of tech-
Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 609
nical injuries is beyond the scope or purpose of this
article, and these subjects are very well covered in stan-
dard texts of laparoscopic surgery.
Intraoperative consultation
The value of intraoperative consultation with a surgical
colleague cannot be overestimated, but that consultation
should occur early in the period of difficulty. I have never
read an operative note, either as a surgeon who has re-
paired biliary injuries or as an expert witness, in which a
surgical colleague was called into the operating room to
assist in the surgery and in the decision-making before
the occurrence of an injury. It seems that the chance of
injury is much lower when this is done, or perhaps if an
injury occurs in the presence of two trained surgeons,
the chance of litigation is reduced. A surgical colleague
in the operating room may be the best stopping process.
Conduct when an intraoperative injury is detected
If an injury is diagnosed intraoperatively, it should be
repaired at the time if the skills required for repair are
within the expertise of the surgeon or an available col-
league. Cystic duct leaks, leaks from the gallbladder bed,
and partial lacerations to the bile duct are within the skill
set of most surgeons. Complete transections of major
bile ducts or aberrant ducts usually require hepaticoje-
junostomy. Several publications now attest to the value
of referral of these complex injuries to a dedicated hepa-
tobiliary service.15-17 Most tertiary care facilities that
house hepatobiliary services have doctor access lines or
“hotlines” that are readily reached through the main tele-
phone number of the hospital. Using this form of access,
expertise can be obtained within minutes from within
the operating room (often operating room to operating
room).
Laparotomy should not be performed for diagnosis or
drainage only. Injury can be extended by dissection,
which is performed solely for diagnosis, drains can be
inserted laparoscopically, and the laparotomy may make
subsequent repair more difficult. Above all, surgeons
should have a plan of what to do in case of suspected or
actual biliary injury, rather than try to formulate one at
a time of increased stress. Poor outcomes after a repair in
the primary institution is “smoke.” Even if the injury
was not negligent and the repair was performed within
the standard of care, the probability of an extensive
search of the evidence is high.
610 Strasberg Biliary Injury in Laparoscopic Surgery, Part 2
The operative note
The operative note should describe the operative condi-
tions clearly and completely but without exaggeration.
When an expert witness reads an operative note that
describes “severe acute inflammation” and the pathology
report notes “mild chronic cholecystitis,” the conse-
quences are obvious. The rationale for cystic duct and
artery identification should be stated clearly and com-
pletely. When the operative note is read later, it should
be readily apparent to the reader why the structures,
which were divided, were believed to be the cystic duct
and artery by the surgeon. The operative note should be
dictated on the day of operation. In most hospitals this is
becoming a requirement. Delay in dictation is “smoke.”
Before beginning the actual dictation, it is wise to take a
moment to jot down a list of the operative conditions to
be dictated into the note and the points that describe the
rationale for ductal identification. If an intraoperative
injury occurs, it should be described in clear terms. If the
extent of the injury is unknown, it is appropriate to state
so. If consultations have been obtained, they should be
described and of course, if a repair is undertaken it
should be included in the note in appropriate detail.
Under no circumstances should a medical record ever be
altered or deleted because this seriously negatively affects
credibility even when done with the best intention of
correcting an error. The appropriate step for error cor-
rection is to enter a note of amendment.
Discussion of intraoperative injury with patient
and family
Occurrence of a biliary injury is very distressing for a
patient and the patient’s family. It is also an upsetting
event for a surgeon. Nonetheless, it is under these con-
ditions that the complication must be explained. The
surgeon, as in the case of being prepared to deal with the
possibility of an intraoperative biliary injury, should
have anticipated and be mentally prepared to discuss
such events with a patient and a family. The process
bears similarities to the consent process except that in-
formation might be necessarily incomplete. Full disclo-
sure of what is known about the injury, and about its
intended or actual investigation and treatment should be
provided in clear and realistic terms. Again, the patient
should be told what to expect as much as is possible from
the patient’s point of view. Judgmental statements about
the cause of the injury should not be made because they
frequently will be inaccurate, especially because the ex-
tent of the biliary injuries is frequently unclear at this
J Am Coll Surg
time. If the patient is to be referred to a tertiary hepato-
biliary center, the referring surgeon should personally
speak to the accepting surgeon whenever possible, con-
vey to the patient that this contact has been made per-
sonally, and provide the name and area of interest of the
accepting surgeon to the patient.
Postoperative care
Postoperative complaints
The most common malpractice claim in gastrointestinal
surgery is that a biliary injury was negligent, but delay in
diagnosis of that injury is probably the second most
common claim. Delay in diagnosis may aggravate the
injury. During the delay, patients are often in varying
degrees of discomfort, which is distressing to them and
equally so to their families. This is especially true if the
laparoscopic cholecystectomy has been described as a
minor procedure. Then there is a “double whammy”
—an unexpected event and the perception that the sur-
geon is not being responsive to complaints. Both cause
resentment and loss confidence in the surgeon, which in
turn, are the triggers for litigation. A contributing factor
to delay in diagnosis is that substantial volumes of he-
patic bile in the peritoneal cavity may cause only minor
symptoms. Hepatic bile is an isotonic fluid, quite dilute
compared with gallbladder bile in respect to irritating
substances such as bile salts. It might leak into the peri-
toneal cavity and produce only relatively minor com-
plaints for days. But these minor symptoms, which may
be feelings of fullness, distention, constipation, or vague
pain should be taken seriously simply because it is un-
usual for patients to have a degree of malaise after a
successful laparoscopic cholecystectomy that would
prompt a call to the surgeon.
To avoid delays and their consequences, the surgeon is
wise to consider postoperative complaints seriously, even
those that do not classically signal a major problem. It is
good practice to interview and examine such patients
and initiate investigations when indicated. In case of
suspected injury, appropriate endoscopic and radiologic
consultation should be obtained as soon as possible.
Complete records should be kept. When the diagnosis is
made intraoperatively, the potential problem should be
explained in a clear and complete way to patient and
family. The patient should be told what the investiga-
tions involve and when they can expect to know if there
is a problem. In this way if injury is present, the chance
of added injury from delay is minimized, patient pain
Vol. 201, No. 4, October 2005
Figure 4. “Think Safety.”
and suffering are reduced, and confidence that the sur-
geon has the best interest of the patient is maintained.
When patient complaints are minimized or ignored and
an injury is present, the opposite occurs. An unjustifi-
able delay in response to symptoms that adds to the
extent of injury may itself be negligent. In the case of
intraoperative injury, when an injury is diagnosed in the
postoperative period, the repair should be performed by
highly experienced surgeons. Other important compo-
nents of this phase of care are that the patient and family
encounter a helpful office staff when they call with com-
plaints and that good records are maintained of such
calls.
In summary, surgeons must take a very active ap-
proach to prevent biliary injury. Biliary injury will not be
eliminated but it can be reduced. Near elimination of
injury will mean near elimination of morbidity and near
elimination of litigation. Adoption of the best methods
of ductal identification (the critical view technique and
cholangiography) would be very helpful. Changing the
culture of cholecystectomy so that the principle is to stay
out of the zone of great danger and adopting the aviation
concept that the goal is no crashes in a large number of
flights ie, no injuries in a large number of cholecystecto-
mies, will increase rates of conversion and cholecystos-
tomies but reduce injuries and be of great overall benefit.
Clear explanations, clear expectations, and clear docu-
mentation will also reduce costly and time-consuming
litigation. When landing from the west at Lambert air-
port in St Louis, one passes the Missouri Air National
Guard facility that is housed behind a fence. Written
large on the fence are two words: “THINK SAFETY”
Strasberg Biliary Injury in Laparoscopic Surgery, Part 2 611
(Fig. 4) — very good words for biliary surgeons to say to
themselves when they begin a procedure.
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