Iatrogenic injury of biliary ducts during laparoscopic cholecystectomy

Damage of biliary ducts (BD) during performance of laparoscopic cholecystectomy occurred in 24 (3.8%) of 635 patients. Damage of BD was identified in good time only in 4 (17%) observations. Noncorrected choledocholithialis and stenosis of major duodenal papilla sphincter were promoted by functioning of biliary fistula in 47% observations.     

Changing referral pattern of biliary injuries sustained during laparoscopic cholecystectomy

Summary: More patients with less severe type biliary injury are being referred earlier to a specialist hepatobiliary unit. Most patients still have ineffective corrective surgery before transfer. Presented in part to the European Congress of the International Hepato-Pancreatico-Biliary Association in Budapest, Hungary, May 1999 and published in abstract form as Digestive Surgery 1999; 16(Suppl 1): 32.     

Iatrogenic injuries to the extrahepatic biliary tract.

Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy. The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.     

Iatrogenic biliary injuries: classification, identification, and management

Iatrogenic biliary injuries most commonly occur during laparoscopic cholecystectomy. Biliary injuries are complex problems requiring a multidisciplinary approach with surgeons, radiologists, and gastroenterologists knowledgeable in hepatobiliary disease. Mismanagement can result in lifelong disability and chronic liver disease. Given the unforgiving nature of the biliary tree, favorable outcome requires a well-thought-out strategy and attention to detail.     

Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review

Traumatic and iatrogenic extrahepatic biliary tract injuries are rare but may lead to exceedingly morbid complications. Traumatic extrahepatic biliary tract injuries represent less than 1 per cent of all traumatic injuries. Iatrogenic injuries result in 0.2 to 1 per cent of laparoscopic or open cholecystectomies. The objective of this study was to review the incidence of biliary tract injuries--iatrogenic as well as traumatic--and their subsequent management. A multi-institutional chart review was done including Louisiana State University Health Sciences Center (LSUHSC)-Shreveport, LSUHSC-Monroe, and Richland Parish medical centers. Charts were reviewed for patients with iatrogenic biliary tract injuries and those with biliary tract injuries related to noniatrogenic trauma. The etiology of the biliary tract injury, symptoms of injury, pertinent laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, days hospitalized, intensive care unit stay, and complications were reviewed. There are 1500 trauma patients admitted to LSUMC-Shreveport each year. The incidence of biliary tract injury in trauma patients admitted to LSUMC is 0.1 per cent. Traumatic injuries were classified according to the injury scale by Mattox et al. (Trauma 1996; Vol 515). There were five Type II, four Type IV, and two Type V injuries. Five patients underwent cholecystectomy, three had endoscopic retrograde cholangiopancreatography with stent placement, and two had choledochojejunostomy; one patient died from associated injuries. There were no complications of repair. Approximately 220 cholecystectomies are done at LSUMC-Shreveport each year. Eighty-eight per cent are laparoscopic, and 12 per cent are open. The incidence of iatrogenic biliary tract injuries at LSUMC-Shreveport during the past 8 years was 0.2 per cent. Immediate diagnosis of iatrogenic injuries was made in five of 17 cases and eight of 11 trauma cases. Laparoscopic injuries were classified by the Way injury classification (Stewart L, Way LW. Arch Surg 1995;130:1123). There were one Type I, one Type II, and nine Type III injuries. Treatment included suturing of the laceration (n = 1), hepaticojejunostomy (n = 8), and primary repair (n = 2). Open injuries were classified using the Bismuth classification. There were one Type I and three Type III injuries. All were treated with hepaticojejunostomy. There were two iatrogenic injuries unrelated to cholecystectomy. One patient suffered a perforation of the gallbladder during laparoscopic nephrectomy. This patient subsequently underwent cholecystectomy and has done well. The second patient suffered ligation of the intraduodenal portion of the common bile duct during hemigastrectomy and oversewing of a duodenal ulcer. This patient underwent hepaticojejunostomy and has done well. Complications of iatrogenic injury repair included leaking of a repaired laceration (n = 1), failed hepaticojejunostomy (n = 1), and an anastomotic stricture after hepaticojejunostomy (n = 1). Laparoscopic injuries by LSUMC hospitals is 0.2 per cent. Extrahepatic biliary tract injuries resulting from open cholecystectomy were diagnosed later than those occurring during laparoscopic cholecystectomy and were most likely to result in stricture formation. Repair of Way Type II and III injuries is associated with a higher complication rate. Hepaticojejunostomy has a complication rate of 15 per cent. Minor common duct lacerations are amenable to conservative therapy with oversewing and/or endoscopic retrograde cholangiopancreatography with stent placement. Repair of extrahepatic biliary tract injuries with hepaticojejunostomy at a level of good blood supply remains our gold standard for treatment of more severe injuries and strictures.     

医源性胆管损伤:胆囊切除术的阿喀琉斯之踵

医源性胆管损伤(iatrogenic bile duct injuries,IBDI)是胆囊切除术的一种严重并发症,其不仅损害病人的身心健康,同时也对外科医生及医保系统造成严重负面影响。IBDI核心在于预防,关键在于及时诊断。把握手术时机,选择合理手术方式,IBDI亦可取得良好的远期治疗效果。本文将从预防、诊断及治疗三方面对IBDI的诊治现状与趋势进行阐述。     

Bile duct injuries during laparoscopic cholecystectomy

Surgical Endoscopy -     

Major vascular injuries during laparoscopic cholecystectomy

Background: Since the introduction of laparoscopic cholecystectomy, major vascular injury has been a rare but very serious complication of the procedure. Methods: All 2,589 laparoscopic cholecystectomies performed at our institution between May 1, 1990, and December 31, 1996, were retrospectively reviewed to identify major vascular injury and the mechanisms involved. All these procedures were performed either by surgical attendings or senior surgical residents. Results: During the 1,372 operations performed here between May 1, 1990, and May 1, 1994, there were three major vascular injuries. One was to a portal vein, due to dissection during lysis of adhesions; the other two, to the aorta and vena cava, were due to trocar insertions. There was one mortality secondary to liver failure following repair of the portal vein injury. Between May 1, 1994, and December 1, 1996, there were no major vascular injuries; our overall incidence was 0.11%. A review of the literature on this subject is included. Conclusions: Laparoscopic cholecystectomy is a very safe procedure; major vascular injury is a rare complication, but mandates early recognition and consideration of prompt exploratory laparotomy. These injuries can be avoided by strict adherence to laparoscopic guidelines: obtaining pneumoperitoneum by the open technique, inserting side trocars under direct vision, elevating the abdominal wall prior to trocar insertion, and training surgeons in a laparoscopic laboratory.     

Bile duct injuries during laparoscopic cholecystectomy

Background: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the ``learning curve,' many occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today. Methods: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray studies, including interoperative cholangiograms and ERCPs, were reviewed. Results: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy. This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon. Conclusions: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery; NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge and skills from his open experience to the laparoscopic technique. Received: 14 May 1996/Accepted: 1 July 1996     

Avoidance of biliary injury during laparoscopic cholecystectomy

Biliary injury during laparoscopic cholecystectomy is still a serious problem. Injury occurs as a result of technical errors or misidentification of ducts. Inexperience, inflammation, and aberrant anatomy are key risk factors. The most serious technical problem is cautery-induced injury. This problem may be avoided by use of cautery under very low power settings in the triangle of Calot. Misidentification injuries occur when the surgeon mistakes the common bile duct or an aberrant right hepatic duct for the cystic duct. This error usually occurs when the surgeon uses the “infundibular” technique to identify the cystic duct. This technique, which depends on seeing the cystic duct flare as it becomes the infundibulum, is especially prone to be misleading in the face of acute inflammation. This technique is unreliable and should not be used alone for anatomic identification of the ducts. It is preferable to use the critical view technique or to perform a cholangiogram. Received: April 20, 2002 / Accepted: May 13, 2002 Offprint requests to: S.M. Strasberg Box 8109, Suite 17308 Queeny Tower, 1 Barnes Hospital Plaza, St Louis MO 63110, USA     

Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3-year period (1995–1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3–98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T-drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux-en-Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.     

Iatrogenic splenic injuries

Inadvertent intraoperative injuries to the spleen by the surgical team represent an underestimated complication of many abdominal procedures. Surgical reports often lack the necessary details and frequently a clear justification as why a splenectomy was indicated is not provided. The wide variability of the incidence reported in literature makes it is difficult to evaluate the morbidity and mortality associated to these injuries and to assess the early and late consequences of this complication, although it is still possible to infer some of the reasons for these inconsistencies and to roughly estimate both clinical and socio-economical effects of this injury. Given the degree of uncertainty on the incidence of iatrogenic and traumatic splenic injuries and on the immediate and long-term sequelae suffered by asplenic patients, we thought that a multicentric prospective study was warranted. We are therefore announcing the start of a study involving several Institutions within the Regione Campania, aimed at obtaining an unbiased estimate of the incidence of these injuries, together with the extent and severity of their long-term complications. We also aim to help promoting a more effective prevention.     

医源性胰腺损伤

医源性胰腺损伤指患者在就医的全过程中所导致的胰腺损伤。其发生率虽然不高,但处理不当时会加重患者痛苦和增加了患者医疗费用,患者常常难以接受,甚至可引发医疗纠纷,给患者及医务人员造成极大损害。为此我们应该及时诊断、采取正确的治疗方法使其损害降低至最低程度,同时还应着手于医源性胰腺损伤的病因预防,从根本上减少它的发生。现本文对其发生的常见原因、诊断、处理及预防做一综述。