Bile duct injury following laparoscopic cholecystectomy

Abstract

Laparoscopic cholecystectomy has been introduced without the caution normally accorded to a new technique and without a controlled study comparing it to the conventional operation. The overall safety of the procedure appears to be similar to that of conventional cholecystectomy but bile duct injury may be more common','. Two cases are reported to emphasize the importance of this complication and to stress the need for careful surveillance of the safety of the procedure. Case reportsPatient 1 A 59-year-old woman was referred with a biliary stricture which developed 3 months after laparoscopic cholecystectomy. At the original operation, the cystic duct was noted to be short and it was thought to insert directly into the right hepatic duct. It was dissected and titanium clips were applied. After operation the patient developed a biliary fistula which closed spontaneously after 2 weeks. Three months later she presented with right hypochondria1 pain and obstructive jaundice. A percutaneous transhepatic cholangiogram showed obstruction of the common hepatic duct and thereafter the patient became deeply jaundiced and febrile.Liver function tests showed a bilirubin level of 234 pmol/l, alkaline phosphatase of 1320 units/l and aspartate transaminase of 31 units/l. A second percutaneous transhepatic cholangiogram showed a tight stricture immediately below the origin of the common hepatic duct ( Figure 1 ) and a biliary leak from the previous cholangiography puncture site. Coeliac axis angiography excluded any hepatic vascular injury. At laparotomy, the peritoneal cavity contained 2 litres of bile. There were extensive adhesions, especially to the gallbladder bed. The stricture was identified just below the level of the biliary convergence and appeared to be related to a titanium clip. This Bismuth type 111 stricture was excised and a hepaticojejunostomy Roux-en-Y performed. The patient recovered uneventfully and was discharged 1 week later. A postoperative 99"Tc-EHIDA (iminodiacetic acid derivative) scan showed good biliary excretion with no anastomotic narrowing or leakage.Patient 2 A 33-year-old woman was referred for assessment and management of a persistent subphrenic bile collection 3 weeks after laparoscopic cholecystectomy. There had been difficulty in identifying the ductal anatomy and two ductal structures were divided which seemed to communicate with the gallbladder. The patient developed persistent right upper quadrant pain and ultrasonography showed a subhepatic bile collection which was drained and a biliary tree of normal calibre. Endoscopic retrograde cholangiopancreatography demonstrated a normal common bile duct and left hepatic ductal system. There was extravasation of contrast close to the clipped cystic duct which filled a large cavity and eventually opacified the right ductal system. The patient was referred with established sepsis.Results of liver function tests were normal apart from a raised alkaline phosphatase level (489 units/l). Coeliac axis angiography excluded any vascular injury. At laparotom...

Cholecystolithiasis: Lithotherapy for the 1990s

“…However, a disturbing incidence of bile duct injury (0.3 to 0.5%) has been noted in several large series (187,188,190,191). This is a serious problem that must not be underestimated (192)(193)(194)(195). Among the seven (0.5%) cases of bile duct injury reported by the Southern Surgeons Club (187), six occurred in the first 25 LCs performed by surgeons.…”

Management of bile duct injuries and strictures following cholecystectomy

“…Thus our experience with management of duct injuries during laparoscopic cholecys-tectomy is limited to two cases only recently referred from another hospital and not included in this report. With the conventional operation, most injuries are not discovered during surgery [28][29][30]. Even if the injury is recognized intraoperatively, it is ditIicult to avoid conversion to an open repair operation.…”

Langzeitverlauf nach Gallengangverletzung durch laparoskopische Cholecystektomie und Rekonstruktion durch ein Jejunuminterponat

“…Neben der Problematik, eine solche Verletzung bereits intraoperativ zu erkennen und in gleicher Sitzung adäquat behandeln zu können, besteht bei den häufig komplexen Verletzungen meist nur die zwar bewährte, jedoch nicht mit befriedigenden Langzeitergebnissen behaftete Möglichkeit der Galleableitung über eine lange Y-Roux-Jejunal-Schlinge. Diagnostik und Verfahrenswahl entsprechen einem durchaus üblichen Vorgehen [3,4,12]. Im vorliegenden Fall wurde bei dem postoperativ rasch auftretenden Verschluûikterus eine hochgradige zentrale Gallengangstenose diagnostiziert.…”

“…Komplikationen durch Anastomosenstenosen, ascendierende Cholangitiden und die Entwicklung biliärer Cirrhosen sind im Langzeitverlauf mit 10±30 % angegeben [1,10]. Die Möglichkeit, Komplikationen der Gallenwegrekonstruktionen, wie hochgradige zentrale Gallenwegstenosen durch die Im- [3,4]. Es erfolgte die Reoperation.…”

“…Unter anderem belegen die Berichte von Kienzle [10] und Pichlmaier [13 ], daû eine zwar seltene aber deletäre Komplikation des Verfahrens eine Verletzung der zentralen Gallenwege darstellen kann. Über eine Reihe von möglichen Rekonstruktionsverfahren nach Gallenwegverletzungen ist mit unterschiedlichen Langzeitergebnissen berichtet worden [1,3,4,6,11]. Über eine Reihe von möglichen Rekonstruktionsverfahren nach Gallenwegverletzungen ist mit unterschiedlichen Langzeitergebnissen berichtet worden [1,3,4,6,11].…”