Is an optical illusion the cause of classical bile duct injuries?

Is an optical illusion the cause of classical bile duct injuries?

Can J Surg 2021;64(1):E1-E2 | PDF

Francis Sutherland, MD; Chad G. Ball, MD; Jennifer Schendel, MD; Elijah Dixon, MD


We sought to determine if lateral–inferior traction on the Hartmann pouch could produce bile duct kinking and subsequent misinterpretation of the space on the left side of the bile duct as the hepatobiliary triangle. Once traction was applied, we measured the angle between the cystic duct and inferior gallbladder wall (hepatobiliary triangle) in 76 cases, and the angle between the common bile duct and common hepatic duct (porta hepatis “triangle”) in 41 cases. The mean angles were significantly different (hepatobiliary triangle mean 68.2°, standard deviation [SD] 16.0°, range 23–109°; porta hepatis “triangle” mean 112.0°, SD 18.4°, range 72–170°; p < 0.01). The ranges, however, overlapped in 26 cases. In many cases, lateral–inferior traction on the Hartmann pouch produced substantial kinking of the bile duct that could easily elicit the illusion that it is the hepatobiliary triangle rather than the centre of the porta hepatis.

Accepted Jan. 23, 2020

Affiliations: From the Department of Surgery (Sutherland, Ball, Schendel, Dixon), University of Calgary, Calgary, Alta.

Competing interests: Chad G. Ball is coeditor-in-chief of CJS. He was not involved in the review or decision to accept this manuscript for publication. No other competing interests were declared.

Contributors: All authors contributed substantially to the conception, writing and revision of this article and approved the final version for publication.

Content licence: This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See:

DOI: 10.1503/cjs.014019

Correspondence to: F. Sutherland, Foothills Hospital, 1403 29th Street NW, Calgary AB T2N 2T9,