Laparoscopic iatrogeny of the hepatic hilum as an indication for liver transplantation

Abstract

The introduction of biliary laparoscopic surgery led to an increase in the incidence of liver hilum injuries. These types of lesions are very serious, because they can lead to secondary biliary cirrhosis or fulminant hepatic failure and the need for liver transplantion (LT). We present three cases of liver hilum injuries, which were treated with LT; one case was due to severe and persistent cholangitis, and two cases were due to fulminant hepatic failure. The world literature is also reviewed, and published cases of iatrogenic lesions of the liver hilum caused by laparoscopic surgery and requiring LT are presented. These iatrogenic lesions of the hepatic hilum are complex and technically demanding, due to their high morbidity and mortality and even the need for LT. In conclusion, these lesions must be always managed in centers with experience in hepatobiliary surgery. (Liver Transpl 2004; 10:147-152.) T he incidence of iatrogenic lesions of the bile duct during open surgery has remained constant at 0.1-0.3% (approximately 1 case per 500 cholecystectomies). However, the introduction of laparoscopic surgery in the 1980s led to an extraordinary increase in this incidence, reaching 0.3-1% (1 per 200 cholecystectomies). 1-3 The lesions were considered to be much more serious due to a higher location in the hepatoduodenal ligament, often affecting the intrahepatic bile ducts and frequently leading to loss of sections of biliary tree. When the bile duct is the only hilar element involved, secondary biliary cirrhosis may be result as a consequence of prolonged cholestasis. 4,5 Lesions affecting the vessels of the hepatic hilum may lead to fulminant hepatic failure 6 -8 and the need for emergency liver transplantion (LT). The aim of this article is to present three cases of laparoscopic-induced iatrogenic lesions of the liver hilum, which resulted in irreversible liver damage requiring LT. The world literature is also reviewed, and published cases of laparoscopic-induced iatrogenic lesions of the liver hilum requiring LT are presented in Table 1. Patients and MethodsThis report involves three cases (Table 1) of laparascopicinduced hilar injuries, two males and one female with a mean age of 50 years (range, 39 -65 years). All of the lesions were caused during laparoscopic surgery for cholelithiasis, uncomplicated in two cases, and for acute cholecystitis in the other. All injuries occurred in other hospitals, and all of the patients underwent reoperation for reconstruction of the injured bile duct (BD) in one case and for hemostasis in the two other cases. Case 1A 48-year-old woman without a history of comorbidities was diagnosed with symptomatic cholelithiasis and underwent elective laparoscopic cholecystectomy in 1994. Bleeding occurred during the operation, and initial attempts to control the bleeding were done by the "blind" placement of multiple clips. As this appeared insufficient, conversion to open surgery was done, which achieved hemostasis with sutures in the liver hilum. During the postoperative period, the pat...

Bile Duct Injury during Cholecystectomy Requiring Delayed Liver Transplantation: A Case Report and Literature Review

“…Nevertheless, it is a technically demanding operation, which can ultimately lead to secondary biliary cirrhosis, especially if it fails in the first attempt (Mirza et al 1997;Nordin et al 2002;Fernandez et al 2004). One possible cause of reconstruction failure may be concomitant vascular injury, which is clinically silent in the majority of the patients (Bilge et al 2003).…”

“…In the absence of extensive hepatic infarction due to vascular injury, the liver can usually be salvaged by treatment of the biliary lesion. However, since 1994, reports of patients who required liver transplantation for secondary biliary cirrhosis due to biliary tract injury (with and without concomitant vascular injury) have been published (Bacha et al 1994;Robertson et al 1998;Loinaz et al 2001;Nordin et al 2001Nordin et al , 2002de Santibanes et al 2002;Fernandez et al 2004) (Table1).…”

Iatrogenic Bile Duct Injuries Following Laparoscopic Cholecystectomy: Myth or Reality? A Recent Literature Review from 2006 to 2011

“…A T-tube has therefore only a decompressive function and does not act as a tutor for a bilio-biliary hazardous anastomosis; it can therefore be used only in selected cases such as partial section or lesion with a proper vascularisation. Finally, unfortunately, there are some complications that may require liver transplantation: IBDI associated with recurrent episodes of cholangitis, chronic cholestasis and secondary biliary cirrhosis, and lesions of the hepatic hilar vessels, especially the hepatic artery, which according to some authors can lead to an acute hepatic failure (Fernández, 2004), although this occurs rarely in a liver otherwise healthy because of its double blood supply .…”

Management of post-cholecystectomy bile duct injury:Review

“…Liver transplantation is rarely indicated in patients with SBC and decompensation or in those with acute vascular injury and acute liver failure [41]. Several small series and case reports of transplant in the setting of biliovascular injury have been reported with mixed results [42][43][44]. Liver transplant in the setting of biliary injury is a complex exercise associated with significant morbidity and mortality [40,41].…”