cagir et al conducted a retrospective analysis of open cholecystectomies and reported a rate of .03% for bile duct injuries . therefore , the rate of bile duct injuries is a 14-fold increase when compared to open cholecystectomy . in a national survey by deziel et al of 77,604 laparoscopic cholecystectomy cases reported the cystic duct leak and bile duct strictures account for 49% and 16% respectively for bile duct injuries . these injuries appear to be related to the proximity of the triangle of calot structures , plus the loss of three dimensional depth perception , anatomic confusion , or possible delayed necrosis from thermal devices . in order to evaluate the risk of delayed injury presentation from thermal devices used within the triangle of calot , the relative distances between these critical structures in cadaveric specimens was compared to the known necrosis depths for laser and electrocautery . the relative impact of cephalad and inferolateral traction on the gallbladder and biliary structures can be measured with the portal triad completely intact . the resected liver specimen included the lateral margin at the right segmental fissure , the medial margin at the left segmental fissure , and the inferior margin including the first through third duodenal segments . measurements were taken between the cystic duct , at the level of the infundibulum , and between the following structures : the common hepatic duct ( c.h.d . ) , right hepatic duct , and the cystic artery . these measurements were taken in triplicate after minimal dissection to allow for identification of the structure . the second measurement defined the proximity with cephalad traction placed on the infundibulum of the gallbladder . the third measurement required inferolateral traction placed on the infundibulum of the gallbladder . in order to maintain anatomic positioning data obtained from previous experiments using a rat liver thermal necrosis model which evaluated depth of thermal necrosis from cautery , sapphire tip laser , non contact yag laser , and the bare tip quartz laser were then applied to the obtained traction measurements to evaluate the potential for injury . equipment used for the thermal devices was : standard valley lab paddle blade electrocautery set at 30 watts , ( lasersonics ) sapphire tip contact laser at a setting of 15 watts , standard yag laser ( lasersonics ) , non - contact quartz fiber at 30 watts , and lab fashioned bare quartz contact fiber at 15 watts . inferolateral traction produced a statistically significant increase in distance between the cystic duct and all three biliary structures . cephalad traction produced a statistically significant increase in length only when compared with the common hepatic duct ( 6.94 mm ) ( table 1 ) . the most frequently used thermal device , electrocautery , has an increased depth of penetration of 1.03 mm . the greatest depth of penetration is seen with the non - contact yag laser at 2.13 mm ( table 2 ) . p values determined using anova ( student - newman - keuls treatment ) thermal necrosis ( at one week ) * end point used was complete dissection through portal tissue with hemostasis inferolateral traction produced a statistically significant increase in the distance between the cystic duct and the critical hilar structures . by applying experimentally obtained thermal necrosis data to the cadaveric measurements , an appreciation for the proximity of these structures and the potential for injury from thermal devices can be obtained . one etiology for a cystic stump leak and bile duct stricture is the inadvertent application of cautery to the respective tissues , causing disruption of the vascular integrity and eventual necrosis . the briefest exposure of the cystic stump or bile duct to cautery may result in stricture and/or necroses that may not become immediately apparent . inflammation and infection may exacerbate the thermal insult . by noting the distance between these critical structures and the increased distance afforded by inferior lateral traction , the laparoscopic surgeon can reduce the risk of thermal injury . deziel et al suggested inferolateral traction , as opposed to cephalad traction , produced the greatest distance between the critical biliary structures . similar suggestion have been made by hunter and berci during sages ( society of american gastrointestinal endoscopic surgeons ) discussions . the measurements obtained from this study confirms these perceptions . other options to reduce the incidence of biliary injury include blunt dissection from the infundibulum to the hepatic hilum , careful identification of the junction between the cystic duct and the common bile duct , and the liberal use of intraoperative cholangiography to clarify the anatomy before extensive dissection . the injury to the biliary system remains one of the most devastating complications in laparoscopic cholecystectomy today . inferolateral traction coupled with meticulous dissection and the judicious use of cautery may reduce the risk of injury to these structures to the lowest possible level .
objectives : do various traction techniques significantly change the anatomic position during laparoscopic cholecystectomy?methods:16 cadaveric liver specimens were dissected and measurements were taken between structures in the triangle of calot . 
 measurements were taken while traction was placed on the infidubilum in the inferolateral , cephalad and anatomic positions . 
 thermal necrosis data was measured one week post - injury in a rat model for noncontact yag laser , quartz , sapphire tip , and electrocautery.results:inferolateral traction provided statistically significant increases in distance ( p<0.01 ) between the critical biliary structures . 
 the increase in length by cephalad traction on the gallbladder was not statistically significant . 
 depth of necrosis for the devices were : cautery 1.03 mm , sapphire tip 0.63 mm , non - contact yag laser 2.13 mm , and bare quartz tip laser 1.05 mm.conclusion:inferolateral traction produced a statistically significant increase in distance between the critical biliary structures . 
 this was not demonstrated with cephalad traction . 
 we recommend avoiding thermal dissection in the triangle of calot due to the thermal devices necrosis depth in relation to the proximity of the biliary structures .