Major Vascular Injury During Laparoscopic Cholecystectomy: The Vasculobiliary Injury Cascade

Abstract

Laparoscopic cholecystectomy is among the most frequent abdominal operations worldwide, and its safety has improved across three decades. Major vascular injury nonetheless remains a rare but disproportionately lethal complication, capable of producing hepatic ischaemia, biliary stricture, liver failure and death. Bile duct injury has dominated the safety literature; vascular injury—isolated or, more often, combined with bile duct injury as a vasculobiliary injury—has been treated largely as bleeding to be controlled. This review argues that this framing is mistaken. Drawing on the observational literature, guidelines and emerging technologies, it advances one thesis: outcome depends far less on the vessel or repair technique than on where the injury sits on a predictable, systems-level cascade running from distorted anatomy, through cognitive fixation and unsafe dissection, to delayed recognition and non-expert management. We formalise this as the Vasculobiliary Injury Cascade, a three-phase model—predisposition, injury and trajectory—in which every transition is a defensible point of interruption and the determinants of survival lie disproportionately in the final phase. From it we derive a mechanism-specific account of prevention separating arterial misidentification from portal dissection injury, a three-layer defence integrating anatomical recognition, operative decision-making and technology, and a management approach of early recognition and timely referral rather than improvised repair.