Mechanisms of major biliary injury during laparoscopic cholecystectomy

Minimal access surgery of the gastrointestinal tract

In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery. Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co-exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectomy and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro-oesophageal reflux, inguinal hernias and jaundice due to non-resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club

BACKGROUND

The use of laparoscopic surgical procedures without previous training has grown rapidly. At the same time, there have been allegations of increased complications among less experienced surgeons.

METHODS

Using multivariate regression analyses, we evaluated the relationship between bile duct injury rate and experience with laparoscopic cholecystectomy for surgeons in the Southern Surgeons Club.

RESULTS

Fifty-five surgeons performed 8,839 procedures. Fifteen bile duct injuries (by 13 surgeons) resulted with 90% of the injuries occurring within the first 30 cases performed by an individual surgeon. Multivariate analyses indicated that the only significant factor associated with an adverse outcome was the surgeon's experience with the procedure. A regression model predicted that a surgeon had a 1.7% chance of a bile duct injury occurring in the first case and a 0.17% chance of a bile duct injury at the 50th case.

CONCLUSIONS

While surgeons appear to learn this procedure rapidly, institutions might consider requiring surgeons to move beyond the initial learning curve before awarding privileges.

Management of bile leaks after laparoscopic cholecystectomy

The success of laparoscopic cholecystectomy has been tarnished by the increased risk of bile duct damage associated with the operation. Many of these injuries can be managed by endoscopic techniques. Experience of such injuries between 1991 and 1994 was reviewed. Twenty-four patients were referred: 11 with injuries to the cystic duct alone, five with complete hepatic duct obstruction and eight with high bile duct leaks. All patients with leaks from the cystic duct were managed successfully endoscopically (sphincterotomy, four; stent, seven) without recourse to further surgery. Patients with complete obstruction were aided in their recovery by endoscopic and percutaneous techniques, either for postoperative problems (two patients) or in preparation for surgery (three). The eight patients with high bile duct leaks were managed endoscopically by stenting (seven patients) or sphincterotomy (one). Stenting appeared to encourage leaks to heal better than sphincterotomy alone; stents should probably be left in situ for 2 months before removal. There were no deaths and all but one patient had normal biliary function at follow-up. It is suggested that all suspected injuries after biliary surgery require management by a combination of interventional radiology and endoscopic interventional techniques. Surgery may be required only if there is complete obstruction of the biliary tree.

Bile duct injury and bile leakage in laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.

Laparoscopic cholecystectomy

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Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Dissection and transection of the cystic duct close to the gallbladder has been advocated as a means of avoiding common bile injury during laparoscopic cholecystectomy (LC). We present three cases in which inadequate identification of the gallbladder-cystic duct junction resulted in incomplete cholecystectomy. In two patients an unsecured gallbladder infundibulum presented as cystic duct leaks and one patient developed recurrent symptomatic cholelithiasis. These cases emphasize the need for complete dissection and visualization of the cystic duct at the gallbladder prior its division and secure ligation during LC.

Technique and results of routine dynamic cholangiography during 528 consecutive laparoscopic cholecystectomies

With the advent of laparoscopic cholecystectomy a trend toward more extensive preoperative diagnostic study of the biliary tree by intravenous cholangiography or ERCP has been observed. However, both exams have technical limitations and are not without risk. We report our experience with 500 consecutive routine dynamic intraoperative cholangiographies during laparoscopic cholecystectomy, 97% of which were successful. No lesions from cholangiography were observed. In ten patients clips on the cystic artery appeared on intraoperative cholangiogram to be too close to the hepatic duct and were removed. Anomalies of surgical importance were discovered in 11 patients (2.3%). Unsuspected stones were found in 18 cases (3.7%) and suspected stones confirmed in 12 (2.4%). In our experience routine dynamic intraoperative cholangiography provided important information in 51 cases out of 500 (10.2%). We conclude that routine dynamic intraoperative cholangiography is extremely useful for safer laparoscopic cholecystectomy and cost containment.

Laparoscopic management of complications following laparoscopic cholecystectomy

Laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis. Although published morbidity and mortality rates compare favourably with open cholecystectomy, bile duct injuries occur far more frequently and technical complications unique to the laparoscopic approach account for a significant number of postoperative deaths. The majority of these complications are dealt with by laparotomy. Two technical complications encountered in a series of 170 patients undergoing laparoscopic cholecystectomy and their subsequent management are presented. One patient suffered a diathermy injury to the common hepatic duct and postoperative bile leak. This was managed successfully by repeat laparoscopy and peritoneal lavage combined with endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the hepatic duct. Another patient sustained a perforated duodenum complicated by peritonitis, subcutaneous wound infection and generalized sepsis. The perforation was repaired at a second laparoscopy using intracorporeal suturing and Tissucol. It is demonstrated that it is possible to deal with some of the technical complications of laparoscopic cholecystectomy with a combination of minimally invasive techniques, sparing the patient from the additional risk of laparotomy.

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

A new minimally invasive technique for cholecystectomy. Subxiphoid "minimal stress triangle": microceliotomy

OBJECTIVE

The authors devised a minimally invasive technique for cholecystectomy via microceliotomy that provides safety attainable with the open conventional approach and postoperative results comparable to laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

Laparoscopic cholecystectomy has evolved as a minimally invasive outpatient procedure. Patients can return rapidly to preoperative status with minimal postoperative morbidity and pain, and the small scar size is cosmetically desirable. Unfortunately, there are reports of serious intraoperative complications, including injury to blood vessels, bowel, and the bile ducts, caused by failure to identify structures properly. The conventional cholecystectomy technique currently is relegated to patients on whom the laparoscopic procedure cannot be performed.

METHODS

Cholecystectomy was performed through a 3-cm transverse high subxiphoid incision in the "minimal stress triangle." The location, anterior to Calot's triangle, was critical in providing a direct vertical view of the biliary ducts during dissection. Direct view cholecystectomy was performed using endoscopic instruments without pneumoperitoneum. Postoperative data were compared with both laparoscopic and open cholecystectomy results.

RESULTS

Using the microceliotomy technique in the ambulatory setting, cholecystectomy was performed successfully in 99.3% (N = 143) of cases. Biliary leakage beyond the third postoperative day was caused by failure of clips or obstruction to bile flow. The postoperative morbidity, acceptability of scar, and analgesic requirements compare favorably with other techniques. Microceliotomy is cost effective. Portal hypertension is a contraindication for this procedure.

CONCLUSIONS

The microceliotomy approach offers a viable, safe, and cost-effective alternative to the laparoscopic technique for cholecystectomy, especially when facilities for laparoscopy are not available or when the laparoscopic procedure cannot be performed.

An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of Defense

OBJECTIVE

This study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries.

SUMMARY BACKGROUND DATA

This is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992.

METHODS

The study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients.

RESULTS

Of the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery.

CONCLUSIONS

The frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.

ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY AS A PRELUDE TO LAPAROSCOPIC CHOLECYSTECTOMY

Seventy patients undergoing laparoscopic cholecystectomy were evaluated with endoscopic retrograde cholangiography (ERC) preoperatively, All the ERCs were performed by the laparoscopic surgeon, 1 to 30 days prior to surgery. In all cases including those converted to open cholecystectomy (5 out of 70, 7.1%), ERC helped in clear delineation of the biliary tree, cystic duct and gallbladder, making dissection of the Calot's triangle safe. Four cases of common bile duct (CBD) stones detected at ERC were managed by papillotomy and basketing. In nine cases (12.8%), anomalies of the biliary tree were detected. Average time taken for ERC was 12 minutes (7-28 minutes); while intraopertaive cholangiogram (one case) took 25 minutes. ERC gives a clear outline of the biliary anatomy and greatly facilitates laparoscopic cholecystectomy, It helps avoid open cholecystectomy because of CBD stones. It also reduces the laparoscopic operating time by the duration normally taken to do intraoperative cholangiography.

Medicolegal analysis of bile duct injury during open cholecystectomy and abdominal surgery

To understand the medicolegal impact of bile duct injury, we analyzed 68 cases of biliary injury resulting from open cholecystectomy and abdominal surgery. Cases were litigated within the US civil justice system between 1970 and 1991. Operations resulting in bile duct complications included cholecystectomy for cholelithiasis in 49 patients (72%), common bile duct exploration in 5 patients (7%), and other abdominal operations in 7 patients (10%); 7 operations were of unknown type. The average delay in recognition of injury was 16 days (range 3 to 42). The mortality rate was 18% (12 of 68). Median jury verdict awards in successfully litigated cases were twice that of out-of-court settlements ($500,000 versus $250,000, P = 0.01). Bile duct injury after open cholecystectomy and abdominal surgery has a high mortality rate when diagnosed late, and is expensive to litigate. This review may be useful in defining the medicolegal outcome of similar injuries from laparoscopic cholecystectomy.

Preceptored introduction of laparoscopic techniques for cholecystectomy into a large university-affiliated medical center

Faced with the task of introducing laparoscopic techniques for cholecystectomy into the practice of a large department composed of individuals with varied backgrounds and experience, our surgical staff decided to grant provisional provileges to five surgeons, two from the full-time faculty and three from the community, who had completed a formal course in laparoscopic cholecystectomy. These five surgeons agreed to assist one another through 10 cases a piece before performing any procedures on their own or serving as preceptors for additional surgeons. Other surgeons could obtain credentials for this procedure by satisfying the same course criteria and receiving assistance from one of the five original surgeons during their first 10 cases. In the 14 months after September 1990, 250 laparoscopic cholecystectomies were performed by 19 different attending surgeons at our hospital. One death from hemorrhage (0.4%) and two bile duct injuries (0.8%) occurred in these patients. One of the bile duct injuries occurred after conversion to open cholecystectomy, as did the hemorrhage, which was from a vessel within the parenchyma of the gallbladder bed which rebled even after temporary control through open ligature technique. The second bile duct injury, the result of injudicious application of hemoclips for hemostasis, was minor in degree and the only injury to occur in a procedure conducted exclusively through the laparoscope. This experience demonstrates that laparoscopic techniques can be safely introduced into an environment involving multiple surgeons by adherence to a careful protocol of preceptored assistance.

Early laparoscopic biliary injury: experience in New Zealand

Data on the incidence, nature and management of early laparoscopic biliary injury up to January 1993 were obtained by a postal questionnaire sent to all New Zealand general surgeons (n = 214; response rate 71 percent) and to all endoscopists who perform endoscopic retrograde cholangiography (n = 16; response rate 100 percent). A total of 41 injuries (surgeons' survey, 22; endoscopists' survey, 19) occurred in an estimated 4000 laparoscopic cholecystectomies; 16 involved the common bile and hepatic ducts, and 25 the cystic and segment V ducts. Operative cholangiography was performed in one patient. The diagnosis of injury was made after operation in 31 of 41 patients and after discharge in 21. Conservative management was undertaken in only 19 patients. This prospective audit documents an increase in the incidence of early biliary injury after the introduction of laparoscopic cholecystectomy in New Zealand. The results highlight the need for further study to determine the best way to ensure early and accurate diagnosis of biliary injury and to define optimal conservative and operative management.

Prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland. West of Scotland Laparoscopic Cholecystectomy Audit Group

Although laparoscopic cholecystectomy has rapidly developed in the treatment of gall bladder disease in the absence of controlled clinical trial data its outcome parameters compared with open cholecystectomy remain unclear. A prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland over a two year period was carried out to attempt to assess this new procedure. A total of 45 surgeons in 19 hospitals performing laparoscopic cholecystectomy submitted prospective data from September 1990-1992. A total of 2285 cholecystectomies were audited (a completed data collection rate of 99%). Laparoscopic cholecystectomy was attempted in 1683 (74%) patients and completed in 1448 patients (median conversion rate to the open procedure 17%). The median operation time in the completed laparoscopic cholecystectomy patients was 100 minutes (range 30-330) and overall hospital stay three days (1-33). There were nine deaths (0.5%) after laparoscopic cholecystectomy although only two were directly attributable to the laparoscopic procedure. In the laparoscopic cholecystectomy group there were 99 complications (5.9%), 53 (3%) of these were major requiring further invasive intervention. Forty patients (2.4%) required early or delayed laparotomy for major complications such as bleeding or bile duct injuries. There were 11 (0.7%) bile duct injuries in the laparoscopic cholecystectomy series, five were noted during the initial procedure and six were recognised later resulting from jaundice or bile leaks. Ductal injuries occurred after a median of 20 laparoscopic cholecystectomies. In conclusion laparoscopic cholecystectomy has rapidly replaced open cholecystectomy in the treatment of gall bladder disease. Although the overall death and complication rate associated with laparoscopic cholecystectomy is similar to open cholecystectomy, the bile duct injury rate is higher.

Endoscopic techniques in management of biliary tract injuries

What can be said with certainty regarding endotherapy for biliary injuries associated with laparoscopic or conventional cholecystectomy? On the one hand, ongoing cystic duct and most bile duct leaks close rapidly after sphincterotomy or placement of a stent or both. Such therapy does not preclude the need for drainage of sizable bilomas. On the other hand, acute and ultimate success of endotherapy appears to be contingent on the degree and perhaps the cause of injury. Although ERCP is useful in diagnosing transection or an inadvertently stapled right hepatic duct, treatment of these conditions remains in the surgical realm. Nor is it likely, in my opinion, that a duct that has been stapled across 75% of its diameter or one with an extremely long stenosis, suggesting devascularization and ischemic injury, will respond to either a radiologic or endoscopic approach. In this setting, ERCP may be used diagnostically, or therapy may be undertaken in an attempt to convert an urgent surgical intervention into an elective and controlled one. Endotherapy appears to be useful, however, for a considerable subset of patients with inadvertent thermal or incisional injury, although need for periodic dilation therapy and exchange of the stent remain limiting factors. Moreover, even in patients with apparent short-term or intermediate-term success, caution is urged to continue periodic clinical and liver function test surveillance because recurrent stenosis may occasionally be subtle and present not as jaundice or cholangitis but as secondary biliary cirrhosis with its attendant consequences.

An alternative technique for laparoscopic cholangiography

The current methods utilized for laparoscopic cholangiography involve cystic duct cannulation and present practical difficulties and potential hazards. An alternative method for intraoperative cholangiography is described which is easy, quick, and safe. The Kumar clamp (a gift from Sabi Kumar, M.D.) is placed across the infundibulum. A 23-gauge sclerotherapy needle is introduced through a side port in the clamp and directed into the infundibulum. The cholangiogram is obtained prior to any dissection in the triangle of Calot, thereby avoiding iatrogenic common bile duct injuries due to misidentification of the cystic duct or anomalous anatomy. To date no pathology has been missed and no complications have resulted from this technique.

Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.

Monopolar electrosurgery and Nd:YAG Contact Laser in laparoscopic intestinal surgery

In a prospective randomized study using a canine model, we compared the use of monopolar electrosurgery (EC) (n = 23) and the Nd:YAG Contact Laser (CL) (n = 21) on intra- and postoperative morbidity in laparoscopic large-bowel resection. In EC, cutting was performed with scissors and coagulation was performed with electrosurgery. In CL, cutting and coagulation were carried out with the Nd:YAG Contact Laser. Laparoscopic oncologic right colectomy with intraperitoneal ileocolic stapled anastomosis was performed in all dogs. Intraoperative smoke development, difficulty of dissection, hemostasis, and postoperative adhesions were judged using a five-point score. Two weeks after surgery, all dogs were sacrificed and zoopsy was carried out. Three dogs died postoperatively from pneumonia and one from an anastomotic leak. There were no other postoperative complications. Operative time was 135 min (range 105-180) in the CL group and 145 min (range 60-210) in the EC group. Intraoperative smoke development, difficulty of dissection, and postoperative amount of adhesions were not different between groups (P > 0.05). Hemostasis in the CL group (median score of 1, range 1-2) was significantly better (P = 0.01) than in the EC group (median score of 2, range 1-5). Scissors and electrosurgery as well as Nd:YAG Contact Laser can be used successfully in intestinal laparoscopic surgery. Although the use of the Contact Laser did not cause less postoperative morbidity than the conventional method, there was significantly better hemostasis using the Nd: YAG Contact Laser.

Endoscopic retrograde cholangiopancreatography following laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.

Minimizing the risk of bile duct injury at laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of operative bile duct injuries. An operative technique that involves commencing the laparoscopic dissection on the body of the gallbladder and dissecting toward the cystic duct has been developed that minimizes the risk of major duct injury. The aim of this study was to assess prospectively the safety of this dissection technique. A group of 410 patients underwent LC for symptomatic cholelithiasis from January 1991 to December 1992. There was a single common hepatic duct injury: a small (1 mm) side hole in a patient with acute cholecystitis and choledocholithiasis. It was managed at open operation with exploration of the common bile duct and insertion of a T-tube. There were no partial or complete common bile duct transections in this series. We concluded that the technique of commencing the dissection on the gallbladder is safe and minimizes the risk of serious common bile duct injury at LC.

Ultrasonic dissection

Following its development for cataract surgery, and gaining widespread use in neurosurgery and liver resection, ultrasonic dissection has been adapted for laparoscopic use. The turbulence, heat, and pressure generated by imploding bubbles disrupts tissues high in water content. This phenomenon is called cavitation and is the principal means by which ultrasonic dissection is accomplished. A randomized, prospective trial demonstrated the utility of the device for laparoscopic cholecystectomy. It was particularly effective in the presence of acute periportal inflammation or fat. Additional experience with a wide range of laparoscopic procedures is being accumulated by several investigators around the world. The laparoscopic use of ultrasonic dissection will be most valuable whenever selective, precise, and, therefore, safe dissection is desired.

Laparoscopic cholecystectomy in a community hospital: experience with 600 laparoscopic cholecystectomies

We reviewed 600 patients who underwent laparoscopic cholecystectomy (LC) in a teaching community hospital from May 1990 to August 1992. The safety, efficacy, morbidity, and mortality of LC, as performed by one surgeon or under his direct supervision, were studied. Five hundred forty-eight patients (91.3%) were treated electively; 52 (8.7%) were admitted for acute cholecystitis (41) or gallstone pancreatitis (11). Mean operating time was 54 min, with a range of 20 to 145 min. Twenty-four (4%) patients required conversion to traditional (open) cholecystectomy. Operative cholangiograms were completed in 106 patients. These revealed choledocholithiasis in 7. Five hundred thirty-seven patients (89.5%) were discharged within 24 h and 564 (94%) within 48 h. The overall morbidity of 9.2% compared favorably with both open and laparoscopic series previously reported. Three patients (0.5%) had small lacerations of the anterior wall of the common duct. Two were recognized and repaired immediately. The third patient came for treatment on the fifth postoperative day and was stented by a T-tube. There was 1 death in this group--a myocardial infarction on postoperative day 4.

Intraoperative cholangiography during laparoscopic cholecystectomy. Routine vs selective policy

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intraoperative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.

Bile leakage after laparoscopic cholecystectomy: biliary anatomy revisited

Bile leakage from the gall-bladder bed following laparoscopic cholecystectomy is recognized as a potential cause of major morbidity. This problem is usually attributed to division of ducts draining a portion of liver directly into the gall-bladder. The authors' experience, however, and a review of the literature suggests that injury to a superficial duct draining into the major hepatic ducts rather than the gall-bladder is the principal cause of this problem. Three patients with bile leakage demonstrated on postoperative biliary tract imaging are presented with a discussion of the literature.

Bile leak from the liver bed following laparoscopic cholecystectomy

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the "ducts of Luschka". Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.

Thermal injury of the posterior duodenum during laparoscopic cholecystectomy

While complications of laparoscopic cholecystectomy occur in 3-7% of cases, bowel injuries are uncommonly reported. Bowel injuries appear to be of two types: penetrating bowel injury from either the Veress needle or trocar, and thermal bowel injury from either contact or conductive burn. The duodenum is usually spared from Veress needle or trocar injury because of its posterior location. However, during dissection in the triangle of Calot, the duodenum is at risk for direct contact burn or energy conduction burn. In this report we describe a presumed conductive burn injury of the posterior second portion of the duodenum which followed laparoscopic cholecystectomy. This unrecognized injury resulted in full-thickness necrosis of the duodenal wall with delayed perforation. This injury was successfully managed with pyloric exclusion. The diagnosis and management of this previously unreported injury are described.

Early experience with minimally invasive surgery: a New Zealand audit

The clinical and economic impact of minimally invasive surgery in New Zealand, especially laparoscopic cholecystectomy, has been profound but uncharted. A postal questionnaire was sent to all general surgeons in New Zealand (n = 214), in order to document the current levels of experience, adequacy of training, levels of equipment and sources of funding. In the case of laparoscopic cholecystectomy, further details were obtained relating to operative technique, complication rates and approaches to the management of choledocholithiasis. The response rate was 71%. From 27 centres, 71 of 106 active general surgeons were performing minimally invasive surgery. Of the 34 different procedures audited, cholecystectomy (3056), herniorrhaphy (178), and appendicectomy (141) were performed most often. Primary funding came from Area Health Boards (71%) and private hospital funds (25%) with 4% coming from other sources. Ten different camera/insufflator systems were used. Training was perceived to be adequate by the majority of surgeons (89%), although seven surgeons had received no specific training. Laparoscopic cholecystectomy technique included: prophylactic antibiotics (89% of surgeons), patients supine (80%), wound infiltration (80%), routine use of diathermy within triangle of Calot (36%) and a routine peritoneal drain (13%). Routine operative cholangiography was used rarely (7%) and 72% of surgeons had deliberately changed their policy with respect to its use. Twenty-two cases of laparoscopic biliary injury were identified by the survey, none of whom had operative cholangiography. The conversion rate was 13% for acute and 4% for elective laparoscopic cholecystectomy. This survey indicated the broad scope of minimally invasive surgery that is being undertaken, and highlights potentially important variations in surgical practice.

Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study

We collected the records of 81 patients with biliary tract injuries occurring during laparoscopic cholecystectomy (LC) who were referred to 3 referral centers during a 33-month (May 1990 to March 1993) period. All records were reviewed to provide data concerning the anatomy of the lesion induced, method of injury, timing of injury detection, role of intraoperative cholangiography (IOC), methods of treatment, and outcome of these injuries. Injuries were classified by our own method as follows: (1) cystic duct leaks (n = 15), (2) bile leaks and/or ductal strictures (n = 27), and (3) ductal transections or excisions (n = 39). Peak occurrence by quarter of the year was 4th quarter, 1990 (Lahey), and 3rd quarter, 1991 (Mason), and 1st quarter, 1992 (Mayo). The majority (62%) of the injuries were recognized after LC. At the time of LC, 31 of 81 (38%) injuries were recognized and converted to open procedures. Data regarding IOC were available in 63 of 81 (78%) cases. In patients in whom IOC was not performed, 14 of 38 (37%) operations were converted; if an IOC was obtained and interpreted correctly, 13 of 21 (62%) operations were converted. Primary repair was attempted in 11 leaks and/or strictures, but 36% required additional treatment. Primary repair was used in six transections or excisions, and 17% have required further intervention. In patients who had biliary-enteric bypass (BEB) performed outside (17) versus at the referral institution (29), 94% (16 patients) versus 0%, respectively, required additional operative (e.g., revision of a hepaticojejunostomy) or nonoperative (e.g., radiologic or endoscopic stenting or balloon dilation) procedures. When used as initial therapy or after a primary ductal repair, stents (with or without balloon dilation) resolved 100% of simple cystic duct leaks and 91% of leaks and/or strictures. In conclusion, the peak incidence of LC-related biliary injuries appears to have passed. A completed and correctly interpreted IOC increases the chance of detection of biliary injuries intraoperatively and should assist surgeons who use routine IOC. Nonsurgical techniques allow treatment of most simple cystic duct leaks, major ductal leaks and/or strictures, and postoperative BEB strictures, although follow-up is limited. The poor results of pre-referral BEB is not surprising since all of these patients were selected for referral because their treatments had not been successful.

Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones, stents and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training, 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy. In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.

Bile duct injury and bile leakage in laparoscopic cholecystectomy

Between January 1991 and July 1992, 350 laparoscopic cholecystectomies were performed. There were six biliary complications (1.7 per cent): common bile duct (CBD) injury (one patient), delayed CBD necrosis (one), immediate postoperative bile leakage (one) and delayed bile leakage (three). All six patients required laparotomy. Primary repair with long-arm T tube splinting for 3 months was performed for the CBD injury. Religation of the cystic duct was carried out after immediate postoperative bile leakage. Laparotomy with T tube choledochostomy only was performed in the three patients with delayed bile leakage, and hepatojejunostomy Roux-en-Y was undertaken for CBD necrosis. The patient with primary repair of the CBD injury required choledochojejunostomy Roux-en-Y 18 months later for stenosis. Episodes of intermittent cholangitis occurred in the patient with CBD necrosis. The outcome for the four patients with bile leakage was good. There were no deaths.

Clinical features and mechanisms of major laparoscopic biliary injury

Laparoscopic cholecystectomy has quickly become the gold standard for the treatment of symptomatic cholelithiasis. With the introduction of this new technique has come a learning curve, with a higher than expected initial rate of complications. The most significant complication, as with open cholecystectomy, is injury to the bile duct. This article reviews the clinical features and mechanisms of major biliary injury in laparoscopic cholecystectomy.

Endoscopic repair of bile leaks after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has quickly eclipsed open cholecystectomy as the standard approach to symptomatic gallstones and acalculous biliary disease. Procedure-related morbidity and mortality continue to be defined, but a higher incidence of bile duct injuries has been reported to date using present technology and procedure. Key principles in the management of these problems include definition of the anatomy, relief of any impedance to biliary-enteric flow, and drainage of significant extrahepatic fluid collections. A cooperative, multispecialty approach involving surgeons, radiologists, and gastroenterologists is critical to successful outcomes. Future studies will help streamline the management of bile duct injuries and aid physicians in their selection of the best approach for each individual patient.

Bile duct disruption after laparoscopic cholecystectomy

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. We have reviewed the first 823 laparoscopic cholecystectomies performed at our institution and found 13 symptomatic biliary complications necessitating further therapy (prevalence 1.6%). This finding represents a decrease from the 2.7% prevalence found in our earlier series. The incidence of biliary complications will likely continue to vary depending on patient selection, operator experience, and new developments in laparoscopic technique. Bile duct injury and bile leaks are often difficult to diagnose but must be strongly considered in postoperative patients with abdominal pain, fever, jaundice, or continued bilious drainage from a surgical drain. Whereas computed tomography (CT) and sonography are sensitive in detecting perihepatic or free peritoneal fluid collections, they are nonspecific and definitive diagnosis of biliary tract injury requires hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or percutaneous aspiration. Disruption of the biliary tree has commonly been treated with reoperation or percutaneous drainage. More recently, endoscopic management has shown encouraging results for bile leaks and strictures in small series.

Bile leakage after biliary tract surgery. A laparoscopic perspective

The incidence of bile leaks has increased with laparoscopic cholecystectomy as compared with open cholecystectomy. Minor bile leaks are not infrequent but are clinically insignificant; of the major bile leaks the most common sequela is the biloma, the most serious, bile peritonitis. Early symptoms may be very subtle; all untoward symptoms should be investigated with a HIDA scan to rule out bile leakage. Positive HIDA scans should be followed with endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiography (PTC). Management of the leakage depends on identification of its source. Prompt identification of ductal injuries permits earlier effective treatment and consequently less morbidity and/or mortality.

Endoscopic retrograde cholangiopancreatography in conjunction with laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has become the primary surgical treatment for symptomatic cholelithiasis. In conjunction with the dramatic rise in LC there has been an increase in the number of endoscopic retrograde cholangiopancreatographies (ERCPs) performed. For this study, the records of patients referred to the surgical endoscopy department between January 1991 and February 1992 were reviewed. Seventy-seven ERCPs were performed in conjunction with LC. The indications for ERCP included jaundice or a history of jaundice, gallstone pancreatitis, a suspicious filling defect on either ultrasound or intraoperative cholangiogram, abnormal liver function tests, cholangitis, or postoperative bile leak. Sixty-two procedures were performed prior to LC and 15 procedures after LC. Forty-two patients were female (54.5%) and the patients ages ranged from 14 to 92 years (mean 54.1 years). Of the 62 patients having ERCP preoperatively 35 patients (56.5%) had no evidence of common bile duct (CBD) stones and underwent LC as planned. Twenty-three patients were found to have CBD stones, of which six were referred for an open cholecystectomy and CBD exploration, because of large multiple CBD stones or the presence of a large duodenal diverticulum. Seventeen patients had their CBD cleared endoscopically, and four patients were not successfully cannulated. Fifteen patients had ERCP after LC. There were two patients with CBD injuries who were referred for surgical correction. Two patients had leakage from the cystic duct stump, and four patients had CBD stones, all of whom were successfully treated with endoscopic sphincterotomy. There were four patients who had a normal postoperative ERCP and two patients who could not have their CBD cannulated.(ABSTRACT TRUNCATED AT 250 WORDS)