Methylene Blue Coloration to Eliminate Bile Duct Injuries During Laparoscopic Cholecystectomy

Sajid Hameed Abd Al-Helfy
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Keywords : laparoscopic cholecystectomy, bile duct injuries, methylene blue, cholecystitis, cholelithiasis
Medical Journal of Babylon  13:2 , 2016 doi:1812-156X-13-2
Published :09 September 2016


Laparoscopic cholecystectomy has superiority over classical cholecystectomy in surgical management of gallbladder diseases. The main disadvantage of LC is an increased number of bile duct injuries. Many techniques have been used to eliminate this complication; however, most of these need specific equipment or expert specialists to interpret the results. The current study aimed to evaluate the efficiency of gallbladder coloration with methylene blue during laparoscopic cholecystectomy in reduction of bile duct injuries.A total of 98-symptomatic cholelithiasis patients were undergone laparoscopic cholecystectomy using methylene blue for delineation of the gallbladder. The gallbladder fundus was grasped and held tight towards the anterior abdominal wall. All the bile was aspirated and 50% or more methylene blue was injected slowly into the gallbladder which was then removed from the abdominal cavity. Operation time, hospital stay and complications, if any, were recorded. In addition, the coloration of different parts in different status of gallbladder was also evaluated. The results showed that mean operation time and hospital stay were 55min and 26hrs respectively. No bile duct injury was recorded, and coloration with MB was visible in four main anatomical parts of the gallbladder (gallbladder, cystic-Hartmann s pouch, junction, cystic duct and common bile duct). In uncomplicated gallstone, almost all parts of the gallbladder colored well; however, a noticeable reduction in coloration was observed especially in cystic duct and common bile duct in complicated cases. Based on these results, it can be concluded that injection of MB could be considered as safe, effective and cheap technique to reduce or even eliminate BDIs during LC.


For more than a century, classical cholecystectomy has been the method of choice in surgical management of gallbladder disease [1]. Asan invasive procedure, cholecystectomy mostly involves abdominal operation. However, the most serious complication associated with this procedure is accidental injury to the common bile duct which occurs in 0.3-0.4% of cases [2]. Introduced in late eighties of the last century, laparoscopic cholecystectomy (LC) became the golden standard for surgical management of gallbladder injuries. It rapidly gained a popular reputation for its efficiency in reduction postoperative pain, recovery time and duration of hospitalization [3]. Furthermore, it results in more acceptable cosmetic outcome and less morbidity and mortality rate compared to open cholecystectomy [4]. Most surgeons started to incorporate this technique in their daily practice. However, a significant increase in bile duct injuries (BDIs) related to this procedure were encountered. Relatively high numbers of these injuries (three to four times higher than that in open cholecystectomy)were found to require bile duct repair [2].These injuries were primarily attributed to the misidentification of the GB anatomy and surgeons experience [5]. Intrinsic factors like excessive fat and hemorrhage in hepatic area were also accused [6]. Although many published series have indicated the low incidence of BDIs (about0.2-0.4%) after LC, they are still somewhat higher than that of traditional open approach (0.1-0.2%) [7,8].Moreover, iatrogenic injuries of the biliary tract after LC have reached a considerable figure [9]. These complications were attributed partly to specific features of the minimally invasive approach [10,11]. A number of technical steps have been emphasized to avoid such injuries; however, the incidence of BDIs reached at least double that observed in open cholecystectomy. Even with the small incidence of BDIs following LC, serious complications may result in long term morbidity. These findings suggest a non-solved problem with LC after many years of the initial learning curve. Several techniques have been used to overcome this problem. Flum et al. [12] used intraoperative cholangiography (IOC) and reported a significant decrease in BDIs (RR=1.7, 95%CI=1.1-2.6). Huang et al. [13] adapted fundus-down LC and found it to be associated with lower complication rate and shorter postoperative hospital stay. Sari et al. [14] used intraoperative methylene blue in 46 Turkish patients and recorded a significant success; however almost all the patients were with uncomplicated cholelihtiasis which implies a normal thickness of gallbladder wall. To further evaluate the efficiency of this technique in preventing BDIs during LC, we used a larger number of patients with different gallbladder status (variable thickness of gallbladder wall).

Materials and methods

A prospective cohort study was conducted for over 30 months from July 2012 to January 2015 to evaluate a new maneuver to reduce BDIs during LC. The study involved 98-symptomatic cholelithiasis patients recruited from Al-Imamain Al-Kadhumain Medical City/ Baghdad. The main complaints at presentation included one or more of these signs: right upper quadrant or epigastric pain, fat intolerance, dyspepsia or flatulence.
From each patient, informed consent form was obtained which included detailed demographic data, medical history and examination, the necessary investigations and operative findings. Exclusive criteria were patients with multidrug allergies and patients with significant renal impairment.
Preparation of Methylene Blue
The standard solution (stock solution) was prepared by dissolving 1.127 g of MB  in 1L  of sterile distilled water [15]. From this stock, the required concentrations of 50% or 60% were then prepared.
Laparoscopic Cholecystectomy
    Patients were undergone sustained LC by one consultant surgeon (the author and his team) in general surgical unit of Al- Imamein Al- kadhmein medical city, Baghdad. The patients were operated upon under general anesthesia (GA). The GB fundus was grasped and held tight towards the anterior abdominal wall with atraumatic graspers and then punctured by a special long needle aspirator/injector which was introduced via the abdominal wall in vicinity of GB fundus. Veress needle was also utilized sometimes. All the bile in the GB was aspirated as far as possible and 50 percent diluted sterile methylene blue equal to the amount of aspirated bile was injected slowly into the GB (figure1). Occasionally, higher concentrations of methylene blue (60% or more), were used to achieve coloration of thickened or fibrotic GB. After injection and withdrawal of needle, the hole(puncture site) in anterior fundus was either clipped or held closed by retracting grasper to prevent a leakage of dye (figure 2). The GB was removed from the abdominal cavity through the trocar inserted from lateral border of the rectus muscle.
Patients who had contracted small GB which was difficult to be punctured and filled with MB due to intra GB mucosal adhesions or stockiness with stones were also excluded. Postoperative follow up was carried out for over one month for any complications.


Results Over 30 months period, 110 patients with symptomatic cholelithiasis were involved among whom 12 patients were excluded due to failure of proper injection of MB. These patients either had contracted thickened GB where the bile was not inspirable, the GB was fully impacted with stones or an extravasation had occurred due to inadvertent submucosal injection with resultant coloration of subperitoneal areas around GB which forced us to stop injection and omit the procedure. In all these cases, the operation proceeded without significant difficulty or complications.Table-1 shows characteristics of patients


Methylene blue has a long history in the medical field. Therapeutic infusion of MB was frequently applied for the treatment of different illnesses [16]. Further, this dye was used in intraoperative localization of parathyroid gland and endoscopic marking during laparoscopic gastrointestinal surgery [17,18].The toxic dose of this dye exceeds 5 mg/kg [19]. Thus it is quite safe in LC because the total capacity of GB is 30-60 ml, and, in case of 60% MB, the total injected dose will be 10.14-20.28mg. The study revealed the efficiency GB coloration with MB in reduction BDIs during LC. These results confirm that of Sari et al. [14]. However, Sari s study did not include the complications escorting cholelithiasis nor the coloration pattern of different parts of GB. Thus, the current study shaded more light and gave more details about this technique. Mean operative time and hospital stay required for LC with MB were found to be 55 min and 26hrs respectively. These periods did not differ significantly, or even less than that in conventional LC. In a recent study by Damani et al. [20] involved 233 patients with chocystitis, they reported a mean operative time of 58hrs and 45hrs for acute and chronic cholecystitis respectively, and a period for hospital stay ranged from 2-6 days. Thus, using MB during LC does not need for extra time neither for operation nor for hospital stay. The Hartmann- cystic duct junction is most important view to be obtained as it is considered the rate limiting step needed to identify cystic duct to be clipped in particular cases of short cystic duct and acute or chronic cholecystitis[21,22]. In our setting, the visualization of this junction was 92.8% under different GB conditions and was 100% in normal wall (uncomplicated) GB which is very significant figure help greatly to reduce incidence BDI. The only limiting problem is the completely impacted stone as inmucocele where the painting diminished. The whole cystic duct is painted in 95.8% in uncomplicated GB which can clearly identify any anomalous or accessory duct aiding to avoid BDI and their morbidity. In the same group of patients, CBD was visualized in our technique by 62.5%, which is significant percent. However, in acute cholecystitis, the coloration rate was low. This can be simply attributed to edema accompanied by narrowing of cystic duct and to wall thickening and congestion which impair clear painting. Knowing that LC in acute cholecystitis has a three times likelihood of causing BDIs than an elective laparoscopic cases [6], it is recommended to increase MB concentration achieve successful coloration. Collectively, the aforementioned data strongly indicate that using MB in 50% or more during LC is a very effective technique in reduction BDIs. Not only is this dye safe, cheap and easily prepared, but also its utilization has no tangible effect on operative time or hospital stay. However, further study involving a comparison with other BDIs preventive techniques are required to definitive recommendation for the using of MB in routine LCs


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