Role for laparoscopy in the management of bile duct injuries

Abstract

Common bile duct (CBD) injury is the most serious complication of laparoscopic cholecystectomy. Recently, laparoscopic techniques have been used in the manage ment of postoperative bile leak and CBD injury; this literature has not been reviewed. We reviewed the literature on CBD injury, the approach to its diagnosis and manage ment, and reports of laparoscopic management techniques. We combined this review with our experience in laparoscopic methods to highlight diagnostic and therapeutic options. Laparoscopic techniques can be used to prevent, diagnose and treat CBD injuries. Intraoperatively, CBD injury can be prevented in the case of short cystic duct with the use of a loop ligature or transfixing suture, and it can be diagnosed using intraoperative cholangiography or other visualization techniques. When CBD injury is suspected postoperatively, repeat laparoscopy can be used to control sepsis with abdominal washout; as a diagnostic tool to guide management; and, in some settings, as a therapeutic tool for suturing small duct leaks, drain insertion and postoperative endoscopic retrograde cholangiopancreatography with sphincterotomy. Definitive laparoscopic repair is possible when certain criteria are met. Open surgery should be considered when the CBD is small, the injury occurred more than 72 hours previ ously, injury or anatomy are complex, port positioning is awkward for repair, or local experience is limited with laparoscopic management. There is an emerging role for laparoscopy in the management of CBD injuries. More case reports and series are needed to show the safety and efficacy of this technique, encourage its wider adoption, and allow outcomes assessment on a larger scale.La lésion du canal cholédoque est la plus grave complication de la cholécystectomie laparoscopique. Récemment, des techniques laparoscopiques ont été utilisées pour traiter les fuites biliaires postopératoires et les lésions du canal cholédoque; la littéra ture à ce sujet n'a pas été passée en revue. Nous avons donc entrepris de faire une revue de la littérature publiée sur les lésions du canal cholédoque, les approches diag nostiques et thérapeutiques les concernant, ainsi que des rapports sur les approches thérapeutiques laparoscopiques. Nous avons combiné cette revue à notre expérience des méthodes laparoscopiques pour mettre en lumière les options diagnostiques et thérapeutiques. Il est possible d'utiliser des techniques laparoscopiques pour prévenir, diagnostiquer et traiter les lésions du canal cholédoque. Durant une intervention, on peut prévenir la lésion du canal cholédoque, dans le cas d'un canal cystique court, en recourant à des boucles de fil préformées ou à des sutures par transfixion; et la lésion peut être diagnostiquée par cholangiographie ou autre technique d'imagerie per opératoires. Lorsqu'on soupçonne une lésion du canal cholédoque en postopératoire, on peut répéter la laparoscopie pour vérifier la présence d'infection et procéder à un lavage abdominal, comme outil diagnostique pour guider le traitement et, dan...

Porta Hepatis Injury during Laparoscopic Cholecystectomy

“…Misidentification of the correct anatomy, anatomic variations in bile duct anatomy or short cystic duct also predispose to ductal injury. Therefore, achieving a critical view of safety is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy [9]. We described the complications of an uncommon vasculobiliary injury in porta hepatis that was caused by laparoscopic cholecystectomy in another hospital; then the patient presented to our hospital, and her complications were managed successfully.…”

“…Intraoperative identification of a bile duct injury allows the possibility of immediate repair or appropriate nonoperative therapy. If an injury is suspected, intraoperative cholangiography can be beneficial in determining the extent of the problem and can help guide definitive repair [9]. Repair (laparoscopic or open) should be attempted only by surgeons with adequate training in hepatobiliary surgery.…”

“…For patients with bile peritonitis, it is important to implement endoscopic retrograde cholangiopancreatography, or percutaneous transhepatic cholangiography, or cholangiography via magnetic resonance cholangiopancreatography. Likewise, control of biloma or bile peritonitis is imperative [9]. So, based on the patient's general stability, location of the injury, its scope and local experience, the surgeon must decide whether to proceed with immediate repair or to delay repair of the injury.…”

Influence of biliary decompression technique on the outcomes of reconstructive surgery

“…Проведение ЛХЭ при остром холецистите, использовании эндоскопической техники из единого доступа увеличивает риск повреждений ЖП [10,11]. Поздно установленный диагноз, неадекватное оперативное вмешательство вызывают формирование рубцовых стриктур и ухудшают результаты лечения ранений главных желчных протоков (ГЖП) [12,13]. В отдаленном периоде через 4 года -9 лет на фоне сформировавшихся стриктур и повреждений сосудов вследствие фиброзной атрофии печени, гепатиколитиаза, портальной гипертензии возникают показания к трансплантации печени [12].…”

“…Поздно установленный диагноз, неадекватное оперативное вмешательство вызывают формирование рубцовых стриктур и ухудшают результаты лечения ранений главных желчных протоков (ГЖП) [12,13]. В отдаленном периоде через 4 года -9 лет на фоне сформировавшихся стриктур и повреждений сосудов вследствие фиброзной атрофии печени, гепатиколитиаза, портальной гипертензии возникают показания к трансплантации печени [12]. Проблема повреждений ЖП связана не только с осложнениями (42,9%), но и с послеоперационной летальностью (1,7%) [9,13].…”