Causes and Prevention of Laparoscopic Bile Duct Injuries

To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. SUMMARY BACKGROUND DATA: Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error.

The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations.