Mechanisms of Major Biliary Injury During Laparoscopie Cholecystectomy

Abstract

Laparoscopic cholecystectomy has become the procedure of choice for surgical removal of the gallbladder. The most significant complication of this new technique is injury to the bile duct. Twelve cases of bile duct injury during laparoscopic cholecystectomy were reviewed. Eight injuries were of a classic type: misidentification of the common duct for the cystic duct, resection of part of the common and hepatic ducts, and associated right hepatic arterial injury. Another injury was similar: clip ligation of the distal common duct with proximal ligation and division of the cystic duct, resulting in biliary obstruction and leakage. Three complications arose from excessive use of cautery or laser in the region of the common duct, resulting in biliary strictures. Evaluation of persistent diffuse abdominal pain led to the recognition of ductal injury in most patients. Ultimately, 10 patients required a Roux-en-Y hepaticojejunostomy to provide adequate biliary drainage. One patient had a successful direct common duct repair, and the remaining patient underwent endoscopic dilatation.

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

“…Bile duct injury: mechanism, classification, and consequences Davidoff et al described ''classical laparoscopic BDI'' as misinterpretation of the common bile duct (CBD) or hepatic duct, as the cystic duct, resulting in clipping and division [23]. Several mechanisms for laparoscopic ductal injury can be identified, including tenting and diathermy injuries [7].…”

Our First Hundred Laparoscopic Cholecystectomies

“…These good results may be because the number of procedures done are few, although complications occur more commonly early in the learning curve, mostly during a surgeon's first dozen or so laparoscopic cholecystectomies and in hospitals which have done less than a 100 procedures [9,10). This was perhaps because we were extremely aware of the possibility of such an occurrence leading to adverse publicity and were particularly careful in avoiding blind clipping and indiscriminate use of electrocautery close to the CBD, which are considered the usual ca.uses of bile duct injury; the commonest and most morbid complication of laparoscopic cholecystectomy [10].…”

“…These good results may be because the number of procedures done are few, although complications occur more commonly early in the learning curve, mostly during a surgeon's first dozen or so laparoscopic cholecystectomies and in hospitals which have done less than a 100 procedures [9,10). This was perhaps because we were extremely aware of the possibility of such an occurrence leading to adverse publicity and were particularly careful in avoiding blind clipping and indiscriminate use of electrocautery close to the CBD, which are considered the usual ca.uses of bile duct injury; the commonest and most morbid complication of laparoscopic cholecystectomy [10]. TABLE 3 Comparison of morbidity/mortality data following laparoscopic cholecystectomy Factors [7] [ The rate of conversion to the open procedure is higher in patients with a palpable mass in the right upper abdomen, a contracted thick walled gallbladder, in the male [15,16] and during the learning curve of the surgeon [17,18].…”

“…A higher rate of complications and conversion to open operation are reported to occur early in the learning curve, mostly during a surgeon's first dozen laparoscopic cholecystectomies, and in hospitals which have done less than a 100 procedures [9][10]. We present our experience of performing the first 10.0 laparoscopic cholecystectomies at Army Hospital (R&R), Delhi.…”

Endoscopic Retrograde Cholangiography as a Prelude to Laparoscopic Cholecystectomy

“…With the initial enthusiasm getting replaced by a more analytical approach, the increasing incidence of biliary injuries assumes importance [6][7][8]. It is also possible to visualize the future laparoscopic surgeon doing cholecystectomies without adequate experience in open opera-…”