Specialist Outreach Service for On-Table Repair of Iatrogenic Bile Duct Injuries – A New Kind of ‘Travelling Surgeon’

Abstract

Ann R Coll Surg Engl 2008; 90: 243-246 243Laparoscopic cholecystectomy (LC) is one of the most commonly performed abdominal operations. Compared to open cholecystectomy, it has a significant reduction in surgical morbidity, a shorter hospital stay and a much faster postoperative return to normal activity. [1][2][3] Although initially attributed to the learning curve, the incidence of iatrogenic bile duct injuries (IBDIs) has remained between 0.5-0.6%, [4][5][6] approximately 17-20% of which are recognised intraoperatively. 7The long-term implications for the patient, surgeon and the healthcare system along with the rising cost of litigation continue to mitigate this otherwise excellent procedure. 8,9 The management outcome of IBDI when it occurs has been shown to be better when such injuries are managed at specialised hepatobiliary centres equipped with a multidisciplinary service. 3,10,11 The availability of surgical expertise to repair small calibre bile ducts high within the porta hepatis, specialised radiological and endoscopic support are the main factors that contribute to the better outcome. In this setting, the long-term outcome of immediate repair of IBDI has also been shown to be comparable with intermediate and late repair. 3,12 The advantages of immediate on-table repair of IBDI include a single anaesthetic and surgical procedure for the patient, and shorter hospital stay. When a specialist hepatobiliary surgeon provides the service of on-table repair as an outreach service, in addition to the added advantage of better surgical outcome, the need to transfer the patient to a tertiary centre is also abolished. As opposed to a delayed repair, an immediate on-table repair nullifies the need for prolonged external biliary drainage and the associated increased risk of sepsis. The disadvantages of such an outreach on-table repair of IBDI are these injuries often being complex, requiring high hepaticojejunostomy reconstructions for non-dilated, normal diameter ducts. Often, the extent of the ischaemic injury suffered by the bile duct is less apparent in the immediate repair setting. 3,12 This could result in a higher incidence of anastomotic strictures requiring subsequent dilatation or surgical repair.

Bile duct injuries after laparoscopic cholecystectomy: 11-year experience in a tertiary center

“…A conversion to laparotomy is required if the operator's experience is limited, or if the anatomy is unclear. An HPB surgeon should be involved in the management and repair as outcomes are significantly better (5,11,12). For minor A lesion, applying a clip or a ligature combined with a transcystic drainage is recommended.…”

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland

“…In at least one part of the UK, specialist hepatobiliary surgeons are currently providing a call-out service allowing bile duct injuries recognised during the procedure to be assessed and primarily repaired without delay within the same procedure. 7 The best long-term results for bile duct repair are achieved in specialist hepatobiliary centres where a Rouxen-Y hepaticojejunostomy is performed. 6,8,9 Flum et al 4 reported that 75% of repairs were attempted by the same surgeon that caused the bile duct injury.…”

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre

“…Our team members reached out to offer expert help and carried out the required repair. The feasibility and positive outcome of such 'specialist outreach service' have earlier been reported [7]. In the latter report, the 'traveling surgeon', when called upon to help, carried along with him some specialized surgical instruments for performing the repair.…”

“…Proper identification of the injury, appropriate timing, technique of repair and experience of the surgeon are paramount in the management of these patients. Some of the recent studies have laid much emphasis on repair by specialist hepatobiliary surgeons and considered this to be one of the most important factors in the successful outcome of BDI [5][6][7]. The present study is a retrospective analysis of all patients with BDI who presented to us during or at a variable period after the index cholecystectomy.…”