Mechanisms of major biliary injury during laparoscopic cholecystectomy

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment for symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC was used to show cystic ducts that are not seen on MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with cystic ducts not seen on MRC. To our knowledge, this is the first study of visualization of a cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.

Surgical Clips Found at the Hepatic Duct After Laparoscopic Cholecystectomy

Surgical clip migration and subsequent stone formation in the common bile duct is a rare but well-established complication after laparoscopic cholecystectomy. There are some suggestions about the mechanisms of the migration process, but the details are still unclear. We report here a case in which common bile duct stones were formed around surgical clips, and other clips were found to have penetrated into the common hepatic duct, which we believe were in the process of migration after laparoscopic cholecystectomy. The patient required a laparotomy to retrieve the bile duct stones due to the distal stricture, and another laparotomy was necessary to remove the penetrating clips, which were deeply embedded in the bile duct wall. Although a variety of endoscopic and percutaneous interventional procedures are available in this era of modern medical technology, it is sometimes impractical to apply these procedures in such cases as ours, and exploratory laparotomy is sometimes required to correctly treat the patient. This case shows that the metallic surgical clips can penetrate into the intact bile duct wall through serial maceration, and we believe that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.

Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy

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Bile Duct Injuries at Laparoscopic Cholecystectomy: A Single-Institution Prospective Study. Acute Cholecystitis Indicates an Increased Risk

During the last decade laparoscopic cholecystectomy (LC) has become established as the gold standard. The drawbacks in the form of bile duct (BD) injuries have also come into focus. We present the results of a prospective, consecutive series of 1568 patients with reference to BD injuries regarding risks, management, and preventive measures. The significant complications of all patients operated upon with LC between October 1999 and December 2003 were recorded prospectively. BD injuries were classified according to Strasberg into types A-E. Transected major BDs, injuries of type E, were regarded as "major" injuries and types A, B, C, and D were "minor" injuries. Major BDs were transected in five patients (0.3%), three of whom had acute cholecystitis. In the two patients operated on electively, the BD injuries were detected postoperatively, while they were detected intraoperatively when the operation was performed of necessity. The BDs were all reconstructed with a Roux-en-Y hepaticojejunostomy. Two patients had anastomotic strictures. Minor BD injuries were encountered in 19 patients (1.2%). The 13 patients with leakage from the cystic duct or gallbladder bed, injury type A, were treated by endoscopic (ERC) stenting without sequelae. Five patients sustained a lateral BD injury, type D; they were treated with a simple suture over a T-tube (at LC) or endoscopically (ERC) without further problems. A transected aberrant right hepatic BD, type C injury, was due to its small-caliber sutured. Minor BD injuries could be managed at the primary hospital if the endoscopic expertise were at hand. Acute cholecystitis seems to be a risk factor for BD injuries.

Isolated right segmental hepatic duct injury following laparoscopic cholecystectomy

PURPOSE

Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach.

METHODS

Twelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients' demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2-90 months).

RESULTS

Three patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed.

CONCLUSION

Successful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.

Ethical issues in innovative colorectal surgery

When physicians and surgeons investigate new drugs or devices, they must adhere to stringent regulatory standards governing human experimentation. Although these standards and regulations are not perfect, they serve to protect the interests of patients and research subjects. By contrast, few standards or regulations exist for innovative procedures, including new surgical techniques. Surgeons apply the term "innovative surgery" to describe practices ranging from minor technical modifications in standard procedures to non-validated investigational approaches indistinguishable from human research. By focusing on recent innovations in surgery, including colorectal surgery, this article proposes an ethical model of surgical innovation that protects patients while maintaining professional self-regulation of surgical advances.

Improving the safety of laparoscopic cholecystectomy: the routine use of preoperative magnetic resonance cholangiography

BACKGROUND

The aim of this study was to determine the value of routinely performed preoperative magnetic resonance cholangiography (MRC) in detecting common bile duct (CBD) stones in patients stated to undergo elective laparoscopic cholecystectomy. In addition, we used MRC to investigate possible variants of the cystic duct.

METHODS

Magnetic resonance cholangiography was performed preoperatively in 773 patients (311 male and 462 female; median age 55 years, range 16-91) who had no clinical signs of cholestasis prior to undergoing elective laparoscopic cholecystectomy. In cases where the MRC was positive for CBD stones, endoscopic retrograde cholangiopancreatiography (ERCP) was then performed. A total of 532 patients were available for continuous postoperatively follow-up (median 54 months, range 36-85). In 462 patients (247 female, and 215 male), MR images were also reviewed for variants of the cystic duct.

RESULTS

In 705 patients (91%), MRC was negative for CBD stones. In 64 patients (9%) MRC was positive. Of these patients, 47 (6%) had CBD stones on ERCP. In 12 patients (2%), MRC was false positive. In five cases (0.6%), ERCP had an inconclusive result postoperative follow-up (532 patients, or 69%) revealed evidence of CBD stones in three patients (10.4%) despite a preoperative negative MRC result. Anatomical variants in the course of the cystic duct and its confluence with the common bile duct were found in 27 of 462 patients (6%).

CONCLUSIONS

Magnetic resonance cholangiography proved to be a reliable screening technique in the preoperative evaluation of patients with silent CBD stones. Imaging of the course of the cystic duct is possible in a high percentage of cases. Therefore, MRC can be recommended as a screening technique before laparoscopic cholecystectomy.

Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out.

METHODS

A Medline, PubMed, Cochrane search.

RESULTS

Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay.

CONCLUSION

The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.

Le risque de plaies biliaires au cours de la cholécystectomie par laparoscopie

The incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. Many injuries are due, rather, to the surgeon's failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon must not hesitate to consider conversion to an open surgical approach. In such complicated cases, even the open approach is not a guarantee against biliary injury; there is no substitute for experience and caution in biliary surgery.

Management of major bile duct injuries after laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries (MBDI) after laparoscopic cholecystectomy (LC).

METHODS

We performed a retrospective analysis of 27 patients who were treated between January 1995 and December 2002 for MBDI after LC at a single unit in a tertiary center. Major bile duct injury was defined according to the Strasberg classification. All patients underwent magnetic resonance cholangiography (MRC), percutaneous transhepatic cholangiography (PTC), or endoscopic retrograde cholangiopancreatography (ERCP) to delineate the biliary anatomy and assess the level of injury. On the basis of the cholangiographic findings, all patients underwent Roux-en-Y hepaticojejunostomy after a waiting period of 8-12 weeks.

RESULTS

A total of 29 hepaticojejunostomies were performed in 27 patients. Seventeen patients (63%) presented with biliary fistula and ascites; 10 (27%) presented with obstructive jaundice. In 14 patients (52%) the MBDI was identified during the LC. Twenty patients (74%) had undergone one or more procedure before referral. Eight patients (30%) had E1, five patients (18.5%) had E2, nine patients (33%) had E3, and five patients (18.5%) had E4 injury. Two patients had early anastomotic stricture, for which redo hepaticojejunostomy with access loop was performed.

CONCLUSIONS

Major bile duct injury after LC commonly presents with biliary fistula and ascites. High-injuries are common after LC. Hepaticojejunostomy repair yields excellent results in these cases.

The standard of laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy?

METHOD

Literature review.

RESULTS

Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones.

CONCLUSION

The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND

Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits.

METHODS

Relevant articles in English were identified from the Medline database, and reviewed.

RESULTS

The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01).

CONCLUSIONS

Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

Laparoscopic cholecystectomy: early and late complications and their treatment

Laparoscopic cholecystectomy gained wide acceptance as treatment of choice for gallstone disease and cholecystitis. With this new technique, not only did the new era of minimal invasive surgery begin, but also the spectrum of complications changed. Laparoscopy-related complications such as access injuries and procedure-related problems are discussed in our article. Typical mishaps are reviewed according to the literature. Set-up of the pneumoperitoneum (morbidity up to 0.2%); bleeding-from trocar sites and vascular injury (mortality up to 0.2%); biliary leaks and bile duct injuries are the main topics in this article (still on a level of 0.2%-0.8%). Aetiology, diagnosis and treatment are discussed, and an overview of the most cited classifications of bile duct injuries is summarised graphically. Finally, bowel injuries as a specific complication in laparoscopy are discussed (incidence up to 0.87%).

CONCLUSION

Careful selection of patients, the knowledge of typical procedure-related complications, and their best treatment are the key points for a safe laparosopic cholecystectomy.

Percutaneous management of bile duct strictures and injuries associated with laparoscopic cholecystectomy: a decade of experience

BACKGROUND

The 1990s were associated with a dramatic increase in bile duct injuries with the widespread use of laparoscopic cholecystectomy (LC). Interventional radiology has an integral role in diagnosing and managing these injuries. Definitive percutaneous management with balloon dilatation might be possible in select patients with intact biliary-enteric continuity, but longterm data are limited.

STUDY DESIGN

Data were collected prospectively on 51 consecutive patients with major bile duct stricture or injury associated with LC, treated with percutaneous management, January 1, 1990, to December 31, 1999. Percutaneous transhepatic cholangiography and biliary catheter placement were followed by balloon dilatation and stenting. Outcomes were assessed with direct patient contact or hospital records.

RESULTS

All patients completed treatment, and 50 (98%) were stent free at mean followup of 76 months. The success rate of percutaneous management was 58.8%, without need for subsequent intervention. Presenting symptoms, level of injury, and number of stents or dilatations did not predict outcomes. Percutaneous treatment was more likely to fail in patients stented for less than 4 months (p < 0.001). Operative repair at Hopkins before percutaneous management was predictive of a successful outcome (p < 0.05). Including subsequent operations or percutaneous management, successful outcomes were achieved in 98% of patients.

CONCLUSIONS

Major bile duct injuries after LC remain a clinical challenge. Although surgical reconstruction is the treatment cornerstone, selected patients with biliary-enteric continuity can achieve successful long-term results with definitive percutaneous management. The combination of percutaneous management and surgical reconstruction results in successful outcomes in virtually all patients.

Postoperative jaundice

Abnormal LCTs after surgery are common, and consultants are frequently called on to evaluate critically ill patients with abnormal tests. All patients undergoing consideration for elective surgery and a history of either acute or chronic liver disease require careful presurgical evaluation. A thorough history and physical examination, complete blood count, routine electrolytes, LCTs, and a coagulation profile should be ordered. For patients with marginal hepatic reserve, it is important that patient well-being be maximized before any elective operation. The type of surgery to be performed should also be reviewed. All patients with postoperative jaundice should be evaluated for a history of liver disease. The consultant should also review the surgical procedure performed, anesthetic agents administered, other medications used, and whether blood products were given during the perioperative and postoperative periods. The pattern and timing of LCT abnormalities may also give a clue to the underlying disorder. As in the preoperative assessment, a routine complete blood count,electrolyte panel, LCTs, and coagulation profile should be ordered. Unconjugated hyperbilirubinemia can develop as a consequence of blood transfusions, underlying hemolytic disorders, resorbing hematomas, drug effects, or Gilbert's syndrome. A haptoglobin, reticulocyte count, LDH, and Coomb's test should be considered in patients with unconjugated hyperbilirubinemia. Treatment is directed toward the underlying condition. Conjugated hyperbilirubinemia can occur as a result of either intrahepatic or extrahepatic disorders. Markedly abnormal aminotransferases and LDH in conjunction with a normal abdominal ultrasound scan suggest ischemic liver injury, drug-induced hepatitis, or viral infections of the liver. Treatment entails restoration of hepatic perfusion, removal of offending medications, and supportive care or antiviral agents, respectively. Extrahepatic biliary obstruction must be considered in all patients with conjugated hyperbilirubinemia. Abdominal sonography is the best screening test to assess for obstruction. Patients with common bile duct stones usually require ERCP with sphincterotomy and stone removal. Biliary strictures or leaks may require ERCP with balloon dilation of strictures or stent placement for strictures and leaks; percutaneous drainage of bilomas in combination with broad-spectrum antibiotic agents is recommended for patients with bile leaks and large intra-abdominal fluid collections. Surgery may be required for patients with strictures or leaks not amenable to either endoscopic or percutaneous intervention or for patients who have transected bile ducts after laparoscopic cholecystectomy. Medication effects, benign postoperative jaundice, sepsis, TPN, and acalculous cholecystitis are responsible for intrahepatic cholestasis and conjugated hyperbilirubinemia. Treatment includes removal of offending drugs, supportive care, broad-spectrum antibiotic agents with drainage of infected fluid collections, adjustment of TPN, and either cholecystectomy or cholecystostomy, respectively.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

Significance of the cystic node in preventing major bile duct injuries during laparoscopic cholecystectomy: a technical marker

Laparoscopic cholecystectomy is associated with an increase in biliary injuries, particularly in acute inflammatory conditions. The cystic lymph node enlarges in most cases of acute cholecystitis. Staying lateral to the node avoids major bile duct injury during dissection of the cystic duct and cystic artery. An enlarged cystic node can thus be used as an endpoint in the dissection of the Calot triangle.

Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures

OBJECTIVE

To compare the clinical presentation and results of treatment of postcholecystectomy bile duct injuries in patients with and without arterial injuries.

SUMMARY BACKGROUND DATA

Incidence and impact of arterial injuries in patients with a postcholecystectomy biliary injury are unknown, although they are claimed to increase the risk of septic complications, difficulty of biliary repair and risk of recurrent stricture.

METHODS

Fifty-five patients referred for postcholecystectomy biliary strictures and who underwent surgical repair were prospectively evaluated by celiac and superior mesenteric angiography. Circumstance and presenting symptoms of the biliary injury in patients with and without vascular injury as well as intra- and postoperative outcome in the 43 patients who underwent a Hepp-Couinaud biliary repair were compared.

RESULTS

Incidence of vascular injury was 47%, the most frequent of which was right-sided hepatic artery disruptions (36%). Indication of cholecystectomy (cholecystitis, 42 vs. 45%), technique of resection (laparoscopy, 80 vs. 79%) as well as delay of recognition and presenting symptom of the biliary injury were comparable in patients with and without vascular injury. Among patients undergoing a biliary repair, the level of the biliary injury (Bismuth's type III or IV 63% vs. 54%), duration of surgery, and incidence of postoperative complications (21 vs. 21%) were also comparable in patients with and without arterial injury. One patient in each group experienced recurrent biliary stricture.

CONCLUSIONS

The discovery of a disruption of the right branch of the hepatic artery should not affect management of the biliary stricture when if a Hepp-Couinaud repair is performed.

Surgeons' anonymous response after bile duct injury during cholecystectomy

BACKGROUND

Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem.

METHODS

A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada.

RESULTS

Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy.

CONCLUSIONS

General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective

OBJECTIVE

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.

METHODS

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.

RESULTS

The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot.

CONCLUSIONS

These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

Postoperative jaundice and total parenteral nutrition-associated hepatic dysfunction

Postoperative jaundice and TPN-induced hepatic abnormalities represent clinical situations that stem from multiple and frequently overlapping insults to the liver. The pattern of LFT abnormalities and appropriate imaging studies provide clues to the diagnosis. Greater insight into the molecular basis of cholestasis has shed light on the possible common pathways for the hepatic derangements that are seen in diverse situations. TPN-related hepatic dysfunction most likely involves a combination of nutritional deficiencies, hormonal imbalances, excessive calories, and possibly bacterial overgrowth in the small bowel. Growing clinical evidence points to a high incidence of severe liver disease in chronic TPN-dependent patients. Careful monitoring of patients is warranted in these circumstances and combined transplantation of the liver and small bowel may be the only possibility for long-term survival for such patients with progressive liver disease.

Management and outcome of major bile duct injuries after laparoscopic cholecystectomy: from therapeutic endoscopy to liver transplantation

Laparoscopic cholecystectomy is associated with a higher rate of bile duct injuries than an open cholecystectomy. The annual incidence of bile duct injuries has remained almost constant and these injuries tend to be more serious, making demands on the method of repair. We wanted to report the management and outcome of major bile duct injuries after laparoscopic cholecystectomy in patients referred to a hepatobiliary and liver transplantation unit. Eighteen patients (14 women), with a median age of 53.5 years were referred to the liver surgery unit with a major bile duct injury after laparoscopic cholecystectomy. The injury was identified after a median of 3 days (range, 0 to 25 days) after operation and the median time interval to referral was 79 days (0 to 2270 days). Fourteen patients had undergone surgery before referral. By the time of referral, four patients had developed end-stage cirrhosis, necessitating liver transplantation. Three of them had undergone bilioenteric drainage operations at the referring institute. Of the remaining 14 patients, three were managed by therapeutic endoscopic procedures. Ten patients were managed with Roux-en-Y hepaticojejunostomy. One died of septic complications before the repair. A median time for hospitalization in our unit was 33 days (range, 10 to 164 days). At present, 16 patients are alive. One patient died of Kaposi's sarcoma 7 months after liver transplantation. A long interval between bile duct injury and referral was associated with the development of end-stage liver disease. Surgery of biliary lesions is demanding, and surgical experience with multidisciplinary approach, including therapeutic endoscopy and liver transplantation, is necessary for successful outcome.

Long-term outcome of hepaticojejunostomy with routine access loop formation following iatrogenic bile duct injury

BACKGROUND

Hepaticojejunostomy is the 'gold standard' procedure for repairing iatrogenic bile duct injuries. The aim of this study was to examine the long-term outcome following hepaticojejunostomy for iatrogenic bile duct injury and the utility of routine construction of an access loop.

METHODS

Patients with iatrogenic biliary injuries were treated with hepaticojejunostomy and access loop by a single surgeon. Injuries were classified according to the Bismuth level. An 'excellent' outcome was achieved if the patient never experienced jaundice or cholangitis in the follow-up period, and the outcome was 'good' if the patient developed symptoms but was asymptomatic for more than 12 months.

RESULTS

Forty-eight patients underwent such operation. There was one operative death. Thirty-three patients were followed for 3 years or more (mean follow-up 80.4 (range 46-118) months). Thirteen of the 33 injuries were Bismuth level II, 13 were Bismuth level III and seven were Bismuth level IV. Outcome was dependent on the Bismuth level (P < 0.001). It was excellent in all 13 patients with Bismuth level II injuries, excellent in seven and good in six of the 13 patients with Bismuth level III injuries, and excellent in one and good in six of the seven patients with Bismuth level IV injuries. Moreover, the need for access loop intervention was dependent on the Bismuth level (P < 0.001). No patient with Bismuth level II injury required intervention, compared with five of 13 with Bismuth level III and six of seven with Bismuth level IV injuries.

CONCLUSION

Biliary reconstruction affords satisfactory long-term outcome. The likelihood of needing the access loop for radiological intervention is dependent on the Bismuth level. The authors recommend that an access loop be constructed in all patients with Bismuth level III and IV injuries.

Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life

OBJECTIVE

To assess the quality of life (QOL) of patients after surgical reconstruction of a major bile duct injury from laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

The incidence of bile duct injuries has increased dramatically since the introduction and widespread use of LC. Previous reports show that at long-term follow-up, most patients surgically repaired will have a successful outcome as measured by standard clinical parameters. However, there is a general impression that these patients have an impaired QOL. Data addressing QOL of these patients are limited.

METHODS

A standard QOL questionnaire was sent to 89 patients after successful surgical repair of a major bile duct injury from a LC treated at the Johns Hopkins Hospital between 1990 and 2000. The instrument consisted of 30 items on a visual analog scale categorized into physical (15 items), psychological (10 items), and social (5 items) domains. The same questionnaire was sent to age- and sex-matched healthy controls (n = 100) and to patients who underwent uncomplicated LC (n = 100). An additional portion of the questionnaire inquired about outcome measures and legal action undertaken by patients.

RESULTS

Overall QOL scores for bile duct injury patients in the three domains (physical, psychological, and social) were 76%, 77%, and 75%, respectively. QOL scores were comparable to those of patients undergoing uncomplicated LC and healthy controls in the physical and social domains but were significantly different in the psychological domain. Presenting symptoms, prior repair, level of injury, number of stents, length of postoperative stenting, and length of follow-up did not influence QOL scores. Repaired patients reported similar rates of abdominal pain, change in bowel habits, use of pain medications, and recent symptoms of fever or chills as LC controls. Thirty-one percent of responding bile duct injury patients reported having sought legal recourse for their injury. All QOL domain scores were significantly lower in the patients who pursued a lawsuit versus those who did not.

CONCLUSIONS

This study provides formal data evaluating QOL after surgical repair of major bile duct injuries from LC. Although there was a significant difference in the QOL as evaluated from a psychological dimension, bile duct injury patients reported QOL scores in the physical and social domains comparable to those of control patients. The decreased QOL assessment in the psychological dimension may be attributable to the prolonged, complicated, and unexpected nature of these injuries. The presence of a lawsuit appears to be associated with a poorer QOL assessment.

Is laparoscopic cholecystectomy a mature operative technique?

BACKGROUND

More than 10 years after its introduction, laparoscopic cholecystectomy has become the method of choice for the treatment of cholecystolithiasis. However intraoperative difficulties with dramatic postoperative consequences have been reported. The aim of this study was to identify what role the two-dimensional view, the surgeon's experience, the instruments, technical tools and their (time) influence exercised on the operation course in daily laparoscopic operations.

METHODS

The operative times for 30 laparoscopic cholecystectomies were investigated by ergonomic sequence analysis and analyzed statistically with the use of the Wilcoxon test.

RESULTS

Comparing experienced and less experienced surgeons, a significant difference in the duration of the operation was observed (56 +/- 24 min compared to 75 +/- 13 min p = 0,025), especially in the laparoscopic intra-abdominal phase of the operation. The prolonged duration of the operation (15-20%) was mainly due to problems with the technical tools (40%) and the use of instruments (23.5%). Visualization had a minor influence (14.4%) on the duration of the operation, and the negative effect of the two-dimensional view (0.5%) was negligible. The last two factors did not cause any complications.

CONCLUSIONS

The recognized difficulties still cause a loss of time and in some cases complications, which can only partly be compensated by the surgeon's experience. This leads to reluctance in the application of laparoscopic cholecystectomy in more complicated stages of the disease. Two-dimensional view satisfies the surgeon's demands for a safe procedure.

Postoperative Bile Duct Strictures

The management of patients with postoperative biliary stricture is a challenging problem that spans across several disciplines. A team approach involving endoscopists, interventional radiologists, and biliary surgeons is crucial for the successful management of individuals with this complex problem. Hepaticojejunostomy is the therapy of choice. Prolonged stenting, either through the percutaneous route or through the endoscopic retrograde route, is an alternative. Stricture recurrence is not infrequent and requires lifelong follow-up.

Absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis

A50-year-old male patient was admitted to the hospital because of fatigue and a palpable abdominal mass. The diagnoses of chronic renal failure and portal vein thrombosis were established by specific investigations. Incidentally, junction of the cystic duct with the left hepatic duct and absence of the common bile duct were found during endoscopic retrograde cholangiopancreatography study. To the authors' knowledge, this is the first reported case of an absence of the common bile duct and junction of the cystic duct with the left hepatic duct in a patient with chronic portal vein thrombosis. Such lesions may cause unexpected complications during biliary surgery.

Changing patterns of traumatic bile duct injuries: a review of forty years experience

AIM: To summarize the experiences of treating bile duct injuries in 40 years of clinical practice.

MATHODS: Based on the experience of more than 40 years of clinical work, 122 cases including a series of 61 bile duct injuries of the Southwest Hospital, Chongqing, and 42 cases (1989-1997) and 19 cases (1998-2001) of the General Hospital of PLA, Beijing, were reviewed with special reference to the pattern of injury. A series of cases of the liver and the biliary tract injuries following interventional therapy for hepatic tumors, most often hemangioma of the liver, were collected. Chinese medical literature from 1995 to 1999 dealing with 2742 traumatic bile duct strictures were reviewed.

RESULTS: There was a changing pattern of the bile duct injury. Although most of the cases of bile duct injuries resulted from open cholecystectomy. Other types of trauma such as laparoscopic cholecystectomy (LC) and hepatic surgery were increased in recent years. Moreover, serious hepato-biliary injuries following HAE using sclerotic agents such as sodium morrhuate and absolute ethanol for the treatment of hepatic hemangiomas were encountered in recent years. Experiences in how to avoid bile duct injury and to treat traumatic biliary strictures were presented.

CONCLUSION: Traumatic bile duct stricture is one of the serious complications of hepato-biliary surgery, its prevalence seemed to be increased in recent years. The pattern of bile duct injury was also changed and has become more complicated. Interventional therapy with sclerosing agents may cause serious hepatobiliary complications and should be avoided.

MR imaging of the gallbladder

T2-weighted imaging and MRCP, which have high sensitivity to edema and fluid, are paramount in the evaluation of certain gallbladder diseases, such as cholelithiasis, cholecystitis, adenomyomatosis, and cystic duct abnormalities. Dynamic gadolinium-enhanced MR imaging has the potential to differentiate among the many nonspecific-appearing lesions involving the gallbladder. MR imaging may not yet replace ultrasound as the workhorse of acute gallbladder imaging. Currently, MRCP is an ideal complementary study to inconclusive sonographic studies and can help plan surgical intervention in the setting of acute cholecystitis. Further investigation of hepatobiliary contrast agents, however, may reveal that MR imaging may be considered as first-line imaging in the acute setting.

Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis

OBJECTIVE

To assess the impact of bile duct injury (BDI) sustained during laparoscopic cholecystectomy on physical and mental quality of life (QOL).

SUMMARY BACKGROUND DATA

The incidence of BDI during laparoscopic cholecystectomy has decreased but remains as high as 1.4%. Data on the long-term outcome of treatment in these patients are scarce, and QOL after BDI is unknown.

METHODS

One hundred six consecutive patients (75 women, median age 44 +/- 14 years) were referred between 1990 and 1996 for treatment of BDI sustained during laparoscopic cholecystectomy. Outcome was evaluated according to the type of treatment used (endoscopic or surgical) and the type of injury. Objective outcome (interventions, hospital admissions, laboratory data) was evaluated, a questionnaire was filled out, and a QOL survey was performed (using the SF-36). Risk factors for a worse outcome were calculated.

RESULTS

Median follow-up time was 70 months (range 37-110). The objective outcome of endoscopic treatment (n = 69) was excellent (94%). The result of surgical treatment (n = 31) depended on the timing of reconstruction (overall success 84%; in case of delayed hepaticojejunostomy 94%). Five patients underwent interventional radiology with a good outcome. Despite this excellent objective outcome, QOL appeared to be both physically and mentally reduced compared with controls (P <.05) and was not dependent on the type of treatment used or the severity of the injury. The duration of the treatment was independently prognostic for a worse mental QOL.

CONCLUSIONS

Despite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient's physical and mental QOL, even at long-term follow-up.

Bile duct injury during laparoscopic cholecystectomy: results of a national survey

OBJECTIVE

To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency.

SUMMARY BACKGROUND DATA

Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern.

METHODS

An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

RESULTS

Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair.

CONCLUSIONS

Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Routine intraoperative laparoscopic ultrasonography with selective cholangiography reduces bile duct complications during laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the preferred treatment for gallstone disease, even in many complicated cases. Perhaps the only downside to LC is a two- to threefold increase in common bile duct (CBD) injuries compared with open cholecystectomy (OC). Intraoperative cholangiography may prevent inj uries, but its routine use remains controversial. Our institution adopted a policy of selective intraoperative cholangiography in 1993. When intraoperative laparoscopic ultrasonography (IOUS) emerged as a viable diagnostic adjunct, it was hypothesized that the routine use of IOUS would facilitate dissection, detect occult choledocholithiasis, and prevent bile duct injuries during LC.

STUDY DESIGN

The experience with LC at our university-affiliated teaching hospital was reviewed. Over a 4 1/2-year period (June 1, 1995, to January 31, 2000), two surgeons used IOUS routinely during LC (ultrasonography [US] group, n = 248); three other surgeons did not (non-US group, n = 594). We compared patient data and outcomes between the two groups. Continuous, data are expressed as mean +/- SEM.

RESULTS

During the study period, 842 LCs were attempted. Patient age (37+/-1 years) and gender (85% female) did not differ between the groups. In the US group, more patients had acute cholecystitis (p < 0.05). More LCs were performed per year by non-US surgeons than US surgeons (45 versus 37). Despite this, all bile duct complications occurred in non-US cases (2.5% overall): five CBD injuries (0.8%), six bile leaks (1%), and four retained CBD stones (0.7%). In the subgroup of patients with acute cholecystitis, there were fewer conversions to OC in US compared with non-US cases (24% versus 36%, p = 0.09).

CONCLUSIONS

IOUS is noninvasive, fast, repeatable, and can corroborate real-time visualization of the operative field. We have found that LC with IOUS is associated with fewer bile duct complications (CBD injuries, bile leaks, and retained CBD stones) than LC without adjunctive imaging. The success rate of LC in cases of acute cholecystitis is slightly higher when IOUS is used as an aid to dissection. In the absence of definitive prospective data, we recommend routine use of IOUS when performing LC, particularly in patients with acute cholecystitis.

How do bile duct injuries sustained during laparoscopic cholecystectomy differ from those during open cholecystectomy?

BACKGROUND AND PURPOSE

Bile duct injuries sustained during laparoscopic cholecystectomy differ from those of open cholecystectomy. The authors conducted a retrospective analysis of their experience with 124 major bile duct injuries to identify these differences.

PATIENTS AND METHODS

Biliary injury in 83 patients (67%) was sustained during open cholecystectomy, while in 41 patients (33%), it occurred during laparoscopic cholecystectomy. Intraoperative recognition was possible in 21 patients (25%) in the former group and in 14 patients (34%) in the latter (P < 0.05).

RESULTS

The median time of presentation after laparoscopic cholecystectomy was 37 days v 240 days after open cholecystectomy (P < 0.001). Twenty-eight patients presented with external biliary fistulae in both groups. Spontaneous closure of these fistulae occurred in 21 patients (75%) in the open cholecystectomy group and in only 10 patients (36%) in the laparoscopic group (P < 0.01). Bismuth type III or IV injuries were the commonest type in the laparoscopic cholecystectomy group (N = 25; 61%) while Bismuth type I or II were the usual injuries in open cholecystectomy (N = 57; 69%) (P < 0.01). After hepaticojejunostomy, over a mean follow-up period of 3.4 years, stenosis of the hepaticojejunostomy was seen in two patients in both groups.

CONCLUSION

Compared with open cholecystectomy, biliary injuries sustained during laparoscopic cholecystectomy are more likely to present earlier, are more often associated with persistent bile leaks, and are usually high injuries. However, the results of surgical repair do not appear to be different in these two groups.

Mirizzi syndrome: an extra hazard for laparoscopic surgery

BACKGROUND

Mirizzi Syndrome (MS) is an important but uncommon complication of gallstones characterized by narrowing of the common hepatic duct (CHD) due to mechanical compression or inflammation. This study aimed to assess the impact of preoperative and intraoperative diagnosis of MS on the performance, safety and efficacy of laparoscopic cholecystectomy.

METHODS

From a consecutive series of 1,281 patients having surgery for gall bladder disease between 1990 and 1998, nine patients with MS were identified from a prospective database and their clinical progress examined.

RESULTS

Five out of the nine patients with MS presented with pain (2/5 were also jaundiced), and four presented with acute cholecystitis. Liver function tests were abnormal in all patients. Preoperative diagnosis of MS based on ultrasound was made in only two patients, and in a third on findings of a nasobiliary cholangiogram. In six patients, the diagnosis was intraoperative. In seven patients cholecystectomy was completed by laparoscopy. Two patients needed conversion to open cholecystectomy. In two patients the common bile duct was mistaken for the cystic duct and the error was recognized on relaxation of traction on the gall bladder in one, but in the other a duct injury occurred that was not recognized until the postoperative period.

CONCLUSIONS

Preoperative diagnosis of MS is difficult, and a high index of suspicion is necessary to avoid serious complications. Once the diagnosis is known, successful laparoscopic management is possible but care should be taken to avoid duct injury.

Bile Duct Injury following Laparoscopic Cholecystectomy: A Cause for Continued Concern

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74,46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Laparoscopic bile duct injuries: spectrum at a tertiary-care center

BACKGROUND AND PURPOSE

Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries.

PATIENTS AND METHODS

From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients.

RESULTS

Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up.

CONCLUSION

The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.

Feasibility of day-care open cholecystectomy: evaluation in an inpatient model

BACKGROUND

Open cholecystectomy is still a fairly frequently performed operation worldwide, and is used where laparoscopic surgery has failed or is contraindicated, and where some surgeons do not operate laparoscopically for technical reasons. In developing countries laparoscopic cholecystectomy is costly and is available only in a few centres. The present study was conducted to assess the feasibility of day-care open cholecystectomy using an inpatient model.

METHODS

Thirty patients were subjected to open cholecystectomy. Intraoperative nasogastric decompression and local wound infiltration with 0.25% bupivacaine was carried out. Postoperatively patients were encouraged to be ambulant, pass urine and start oral fluids. Intravenous fluids and parenteral medication were stopped at 8 p.m. when patients were assessed for feasibility for discharge. All patients were reassessed the next morning for any adverse effects that could have occurred had the patients been discharged on the evening of surgery.

RESULTS

Prospectively, 73.3% of patients were considered to be dischargeable on the evening of surgery; but on reassessment the next morning, retrospectively, 93.3% of patients were actually dischargeable on the evening of surgery. A total of 76.6% of patients was actually discharged within 24 h of surgery. No patient required readmission. On follow up there were no complications that could be attributable to early discharge. A total of 83.3% of patients approved of day-care open cholecystectomy.

CONCLUSIONS

Day-care open cholecystectomy is safe and feasible. In developing countries, where the use of laparoscopic surgery is limited due to resource constraints, day-care open cholecystectomy can lead to substantial savings in health-care resources.

The prevention of bile duct injury during laparoscopic cholecystectomy from the point of view of anatomic variation

The aim of this study was to evaluate ways to prevent bile duct injury during laparoscopic cholecystectomy in patients with anomalous biliary tract anatomy. The biliary tract was studied using cholangiograms of 511 patients who had gallbladder disease and was dissected in 92 cadaveric specimens. The authors classified confluent forms of the cystic duct and the bile duct into five different types, including four anomalous types. Sixteen instances (3.13%) of anatomic variation of the biliary tract were found among the patients, and four cases (4.35%) were found in the cadavers. Among the 511 patients, there were 495 cases of type C anatomy, three cases of type A, seven cases of type R, six cases of type P, and zero cases of type L; among the 92 cadaveric specimens, there were 88 cases of type C anatomy, one case of type R, two cases of type P, and one case of type L. For anatomic types A, P, and R, there is a high probability of risk of cutting the wrong duct. Therefore, it is important to clarify the anatomy of the biliary tract by preoperative examination and to carefully dissect the cystic duct close to the neck of the gallbladder during laparoscopic cholecystectomy. Anatomic variation of the biliary tract is common and can create a rare pitfall during laparoscopic cholecystectomy.

The "hidden cystic duct" syndrome and the infundibular technique of laparoscopic cholecystectomy--the danger of the false infundibulum

BACKGROUND

The "classical" biliary injury usually involves misidentification of the common bile duct as the cystic duct. The purpose of this study was to determine if the method of cholecystectomy, specifically the "infundibular technique," might be a contributing factor in this injury.

STUDY DESIGN

Twenty-one operative notes of patients who were referred with injury to the common bile duct were examined. Notes were classified as to informativeness. Patient and operative variables potentially related to injury were searched for.

RESULTS

Inflammation was the main patient variable associated with injury. The main operative variable was that in most of the injuries the cystic duct was isolated and divided as the first step in the procedure. Often the operative note contained a statement indicating that the surgeon believed that the "cystic" duct (actually the common bile duct) was emanating from the infundibulum of the gallbladder and that this was the anatomic rationale for identification of the cystic duct. In no case was the triangle of Calot completely dissected before injury.

CONCLUSIONS

The cystic duct may be hidden in some patients having laparoscopic cholecystectomy, especially in the presence of inflammation. This may lead to the deceptive appearance of a false infundibulum that misleads the surgeon into identifying the common duct as the cystic duct. Biliary injury is more likely when cystic duct identification is made by relying solely on the appearance of the junction of the cystic duct with the infundibulum of the gallbladder, and this technique should be abandoned.

Biliary complications associated with laparoscopic cholecystectomy--an analysis of common misconceptions

BACKGROUND

Several views are expressed by surgeons on biliary complications following laparoscopic cholecystectomy as follow: most are caused by trainees; complications occur in the presence of difficult anatomy/pathology; injuries occur more proximally than at open cholecystectomy; most injuries are recognised immediately and most can be managed non-operatively. The aim of our study was to determine if these views are substantiated in clinical practice.

METHODS

The mode of presentation, management and outcome of thirty-two patients referred to a hepatobiliary unit over a seven year period were analysed.

RESULTS

In 72% of cases the initial operator was a consultant. Five of the 32 complications (16%) occurred in the presence of difficult anatomy/pathology. Two patients had proximal biliary tree injuries, the only mortalities (two) occurring in this group. Only 41% of injuries were detected immediately; 87% required surgical intervention, hepaticojejunostomy being the most common procedure performed (75%).

CONCLUSION

Our study shows that the majority of bile duct injuries are not caused by trainees, do not occur because of unusual anatomy/pathology, do not occur in the proximal biliary tree and are not recognised at the time of operation. Most injuries ultimately require major reconstructive surgery for definitive management.

Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is associated with an increased incidence of bile duct injuries when compared with the open surgical technique. Long-term results of repaired injuries and hepatic damage associated with chronic biliary obstruction are lacking.

METHODS

From Aug 1, 1991 until Dec 1, 1999, there were 27 patients referred for management of complex biliary injuries that occurred during LC. Patients underwent percutaneous transhepatic cholangiography and placement of transhepatic catheters with computed tomography-guided biloma drainage when indicated. On the basis of the cholangiography findings, patients underwent Roux-en-Y hepaticojejunostomy (HJ) and liver biopsy or were treated with nonsurgical interventions.

RESULTS

Twenty-one of 27 patients (77. 8%) underwent HJ, and 16 of these 21 patients (76.2%) also underwent hepatic biopsy. In 1 patient, a recurrent stricture developed at 20 months after the initial repair; and, in a second patient, an episode of cholangitis developed in the postoperative period with the transhepatic catheters in place. Five of 16 patients (31.2%) demonstrated marked hepatic fibrosis with 4 (25%) of these patients showing evidence of evolving cirrhosis at the time of HJ.

CONCLUSIONS

In this series with 55 months of follow-up, HJ repair of LC injuries was associated with an initial 95.2% success rate and an ultimate success rate of 100%. Despite this, delayed referral, averaging 12 months, was associated with significant hepatic injury in 5 of 16 (31.3%) patients who underwent biopsy.

Outcomes assessment and minimally invasive surgery: historical perspective and future directions

BACKGROUND

Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations.

METHODS

Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced.

CONCLUSIONS

Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling.