Laparoscopic Biliary Injury: More Than a Learning Curve Problem

Abstract

Background:The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC. Methods: A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n = 184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) ( n = 18, response rate 100%). Results: The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1 % vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61 % of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%). Conclusions:The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.

Postoperative Bile Duct Strictures: Management and Outcome in the 1990s

“…3 Similarly, the results of a nationwide audit in New Zealand demonstrated that despite increasing experience with LC, the incidence of iatrogenic bile duct injury remained stable. 22 Therefore, we can assume that bile duct strictures and injuries will continue to be a problem well into the new millennium.…”

Curva de aprendizado e lesões iatrogênicas em colecistectomias videolaparoscópicas

“…Os principais motivos apontados para explicar a maior incidência destas lesões foram a presença de reação inflamatória intensa, variações anatômicas do pedículo biliar, sangramento durante a operação, uso indiscriminado do termocautério, a qualidade do equipamento e, a mais importante de todas, a inexperiência do cirurgião com o novo método [7][8][9] . Observou-se que, com o desenvolvimento da habilidade e ganho de experiência, estes índices tornavamse menores e comparáveis aos dos procedimentos chamados convencionais.…”

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

“…Traditionally, surgeons opt for operations with lower complication rates, and the ''learning curve'' was one of the arguments to account for the increased incidence of BDIs during LC [12]. However, further publications have reported that this incidence remains higher even when ''learning curve'' is accounted for [4,13,14], even in light of technological advances that have improved visualization and instrumentation [14][15][16][17][18]. Despite this evidence, LC remains the treatment of choice for symptomatic gallstones, a fact most likely attributable to the benefits of less postoperative pain, shorter hospital stay, better cosmetic result, and increased patient satisfaction [12,[19][20][21][22].…”