Bile duct injury after laparoscopic cholecystectomy

Background: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection. Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically, percutaneously, or operatively. Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%. Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction. Received: 24 September 1996/Accepted: 28 July 1997     

Bile duct complications after laparoscopic cholecystectomy

Summary A retrospective review and analysis of patients referred to the Division of Gastroenterology and the Section of Gastrointestinal Surgery with common bile duct complications after laparoscopic cholecystectomy was undertaken in order to identify injury patterns, management, and outcome. Sixteen patients were identified over a 20-month period. Twelve patients had major common bile duct injuries and four had minor injuries (cystic duct leaks). Seventy-one percent of injuries occurred with surgeons who had done more than 13 laparoscopic cholecystectomies. Eighty-three percent of patients who had major ductal injury did not have a cholangiogram prior to the injury. Sixteen percent of patients with major common bile duct injuries had findings of acute cholecystitis and 58% of these major injuries were easy gallbladders. One-third of major injuries were recognized at operation. Two-thirds of immediate repairs failed. All cystic duct leaks were managed nonoperatively.It appears that bile duct complications after laparoscopic cholecystectomy are more common in the community than is reported. Bile duct complications occur with surgeons who are experienced and inexperienced with laparoscopic cholecystectomy. Common bile duct injuries, unrecognized at laparoscopic cholecystectomy in the majority of cases, usually occur with easy gallbladders. Operative cholangiography is not utilized in the majority of common bile duct injuries. When immediate repair of common bile duct injuries is undertaken, the majority are unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) is invaluable in the diagnosis and management of bile duct complications. Cystic duct leaks may be managed successfully with endoscopic stents.Presented at the annual SAGES meeting, April 10–12, 1992, Washington, D.C.     

腹腔镜胆囊切除术胆管损伤46例报告

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中减少或避免胆管损伤的术中判断和操作技巧。方法回顾分析我院1992年10月～2005年10月39860例LC的临床资料，其中胆管损伤46例。结果行胆管裂口修补，置T管支撑引流26例；游离两断端，做端端吻合，T管支撑引流4例。T管支撑时间3～12个月。胆管空肠的Rouxen-Y吻合11例；副肝管结扎5例。胆管狭窄再手术4例，胆肠吻合口狭窄再手术2例。结论深刻的解剖认识，熟练的操作技巧可以避免或减少胆管损伤的发生。早期诊断和处理胆管损伤避免急性炎症期是防止多次胆道手术的重要举措。     

腹腔镜胆囊切除术中粗大胆囊管处理体会

目的　探讨腹腔镜胆囊切除术中粗大胆囊管的处理方法。　方法　回顾分析 1995年 5月～ 2 0 0 1年 12月我院 10 5 2例LC中 2 4例粗大胆囊管的临床资料 ,其中胆囊管 (0 4～ 0 6 )cm 12例 ,(0 6～0 8)cm 8例 ,(0 8～ 1 0 )cm 2例 ,>1cm 2例。分别采用二夹法 (10例 ) ,三夹法 (5例 ) ,梯形钳夹法 (6例 ) ,旋转钳夹法 (3例 )处理。　结果　 2 1例顺利完成LC ,3例因术中出血中转开腹。全组无胆漏、膈下积液发生。　结论　腹腔镜胆囊切除术中粗大胆囊管采取不同方法处理可顺利完成LC。     

Bile leakage following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management.From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy—one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent.Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.     

Bile leak after laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy has now become the preferred surgical approach to symptomatic cholelithiasis. With the widespread use of this technique there have appeared reports of complications. We report the case of a patient who developed a cystic duct stump bile leak after laparoscopic cholecystectomy. Percutaneous drainage of the biloma, endoscopic retrograde cholangiopancreatography and papillotomy led to resolution of the problem. The literature on cystic duct stump leaks after laparoscopic cholecystectomy is reviewed and the various therapeutic modalities are outlined.     

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     

腹腔镜胆囊切除术中特殊类型胆囊管的处理

目的介绍腹腔镜胆囊切除(LC)术中对某些特殊类型胆囊管的处理方法。方法本组12000例LC中约5％的胆囊管具有特殊解剖或病变解剖形状，对其腹腔镜下的处理技术及结果进行了回顾性分析。结果2例因直径过细而漏夹闭或直径过粗而夹闭不全的胆囊管术后出现胆汁漏，1例因胆囊管电热损伤，于术后第9天发生胆汁性腹膜炎。其余病人均获得一期恢复。结论LC术中宜根据这类特殊胆囊管的具体病变和解剖，针对性地采用不同的处理措施来避免常规方法可能带来的诸如胆囊管残端漏、肝外胆管损伤、胆囊管残留结石等并发症。     

The significance of cystic duct stones encountered during laparoscopic cholecystectomy

Background: Cystic duct stones (CDS) are occasionally encountered during laparoscopic cholecystectomy (LC). They may be noticed during the dissection of the cystic pedicle or seen to extrude from the cystic duct (CD) when it is divided or opened to perform the intraoperative cholangiogram (IOC). The procedures for dealing with CDS range from the simple removal of stones that fall out when the duct is opened to incising the duct over an impacted stone to facilitate its removal or converting to open surgery due to a large stone in a CD adherent to the bile duct (e.g., Mirizzi syndrome). Therefore, we set out to establish criteria that might be predictive of CDS, to examine the technical problems caused by them, to look for the most effective ways of avoiding adverse consequences, especially the risk of missing bile duct stones. Methods: We performed a review and analysis of a database that included preoperative, operative, and postoperative data for all patients treated at our hospital who were found to have CDS. Results: In a series of 520 LC performed over a period of 5 years, 64 cases of CDS were documented (12.3%). The preoperative risk factors in 45 of these cases (70.3%) were recent sever acute pain with or without liver function test (LFT) derangement (34.3%), jaundice (14%), pancreatitis (14%), and previous acute cholecystitis (7.8%). At operation, a single stone was found in the CD in 64% of the cases; multiple stones were found in 36%. Dissection of the pedicle was difficult in 21 cases and had to be carried out fundus-first in four cases. The CD was reported to be wide in 18 cases; five of them eventually needed to be closed with endoloops. Operative difficulty was reported in three of 19 cases where there were no preoperative risk factors. Simple removal of the stones was possible in most cases. CDS needed be crushed, the CD incised, or the procedure converted to open in only five cases (7.8%). IOC was attempted in all cases; it was normal in 39 (61%) and failed in two cases (3%). Eighteen patients (28%) were found to have bile duct stones; another five (7.8%) had CBD dilation or debris indicating possible recent passage of stones. Fourteen transcystic and nine direct bile duct explorations were performed. Conclusion: Some CDS may slip from the gallbladder into the CD or the CBD during dissection. Careful retraction and manipulation should therefore be done to minimize this risk. Most CDS are easy to deal with, but some of them can result in increased operative difficulty. If IOC is not carried out on a routine basis, it becomes mandatory if CDS are encountered because \leq35% of them may be associated with bile duct stones. apd: 13 March 2001     

A new bipolar feedback-controlled sealing system for closure of the cystic duct and artery

Background: Bile leaks are serious complications after laparoscopic cholecystectomy. The aim of this study was to evaluate the feasibility of closure of the cystic duct with a new feedback-controlled bipolar sealing system (LigaSure).Methods: Ten domestic pigs underwent open cholecystectomy with the cystic duct and artery dissected and sealed with the new bipolar sealing system (LigaSure). Four and 8 days postoperatively, 5 pigs each were sacrificed and the closure of the cystic duct was evaluated. The cystic stump and the common bile duct were excised for histological examination. Results: None of the pigs had a bile leak or a biliary peritonitis. There were no signs of postoperative bleeding or inflammation in Calot’s triangle. Histology showed total necrosis of the cystic duct in the first two pigs due to too much energy used. The remaining specimens showed a regularly scaling zone without necrosis in 7 cases, and in one case a partial necrosis in the mucosa only was found.Conclusion: Cystic artery and cystic duct closure with the new device may be an alternative to the clip. Further trials should evaluate the feasibility and safety of the new device in the clinical setting.     

Absorbable clips for cystic duct ligation in laparoscopic cholecystectomy

Background The efficacy and applicability of an absorbable polydioxanone (PDS) clip for cystic duct ligation were evaluated in 297 patients undergoing laparoscopic cholecystectomy. Methods The indications for cholecystectomy were symptomatic gallstones (179 patients), acute cholecystitis (67), biliary pancreatitis (23), acute cholangitis (24), and gallbladder polyp (4). Results Twenty-five patients required conversion to open surgery (8.4%). The conversion rate was 2.7% for uncomplicated and 17.5% for complicated gallbladder diseases. Of the 272 patients with laparoscopic cholecystectomy, the cystic ducts were successfully ligated with PDS clips in 227 patients (83.5%). The success rate was higher in uncomplicated (163/178) than in complicated (64/94) gallbladder diseases (chi square = 24.6,P < 0.001). There was no clip-related complication on follow-up (range 0.4–39.2, median 17.5 months). In 45 patients, PDS clip failed. They were treated with endoloop (14 patients), Roeder slip knot (13), metallic clips and endoloop (8), metallic clips alone (6), and intracorporeal tie (4). Conclusions The PDS clip is effective and applicable to the majority of patients. It should be attempted first because of the ease of application. This study is not supported by any grant.     

腹腔镜胆囊切除术致胆管的热力损伤

目的探讨腹腔镜胆囊切除术致胆管热力损伤的原因、特点、处理及预防方法。方法回顾总结我院1992-2002年间收治的腹腔镜胆囊切除术致胆管热力损伤的8例临床资料。结果6例表现为穿孔性损伤：右肝管损伤1例，肝总管损伤4例，胆总管损伤1例，经过1次或1次以上手术治疗后痊愈；2例表现为延迟性胆管狭窄，均为肝总管损伤，再次手术后痊愈。随访1．5～9年，无胆管狭窄。结论与机械性胆管损伤相比，腹腔镜胆囊切除术致胆管热力损伤具有一定的特点，且其病情复杂、处理困难、处理方法灵活多样；娴熟的腹腔镜技术、正确掌握中转开腹指征以及丰富的胆道外科经验是预防和处理胆道热力损伤的关键。     

腹腔镜胆囊切除术胆道损伤的临床分析

目的 总结腹腔镜胆囊切除术胆道损伤的原因、预防措施、诊断及处理方法.方法 回顾分析我院从2008年1月～2013年1月处理的14例腹腔镜胆囊切除术胆道损伤的临床资料.结果 在14例患者中,A型（3例）经闭合离断的小胆管＋腹腔引流术治疗,C型（1例）和D型（5例）经肝胆管的修补＋T管引流术＋腹腔引流术治疗,E1型（3例）和E3型（1例）经肝管-空肠Roux-en-Y吻合术＋腹腔引流术治疗,E4型（1例）经融合左右肝管后再行的肝管-空肠Roux-en-Y吻合术＋腹腔引流术治疗.14例患者术后随访6～60月,均恢复良好.结论 胆道损伤是腹腔镜胆囊切除术的严重并发症,我们在了解其主要原因的同时应尽力避免损伤,一旦出现需及时正确处理,以达到满意的预后.     

腹腔镜胆囊切除并胆总管探查术胆囊管入路法347例临床总结

目的探讨腹腔镜胆囊切除并胆总管探查术中行胆囊管入路一期缝合预防胆道损伤及胆管狭窄的临床意义。方法 2009年1月至2014年4月北京军区总医院肝胆外科应用腹腔镜胆囊管入路法行胆囊切除及胆总管探查一期缝合术347例,对其临床资料进行分析。结果以胆囊管为解剖学标志,顺利显露胆囊壶腹部、胆囊管及胆总管,以胆囊管与胆总管移行区为胆总管探查入路,均成功进行了腹腔镜胆囊切除及胆总管探查术,并行胆总管一期缝合,术中未发生血管、胆管损伤,术后随访8~24月,未发现胆管狭窄。结论在腹腔镜胆囊切除及胆总管探查术中,采用胆囊管入路法,通过胆囊管与胆总管移行区行胆总管探查一期缝合术是一种安全、可行的方法,可有效避免胆道损伤及胆管狭窄的发生。     

A miniature probe enables clear demonstration of the cystic duct during laparoscopic cholecystectomy

We performed intraoperative ultrasonography with a miniature probe to explore the biliary anatomy, especially the cystic duct, during laparoscopic cholecystectomy. By using this radial-type probe introduced into a hard metal sheath with a balloon at the end, the plane containing Calot's triangle can be scanned easily when the gallbladder is extracted to the right side, thereby facilitating the identification of the cystic duct as well as the common ducts. In 30 cases, no common duct stone was found and the cystic duct was clearly identified. This radial-type miniature probe can be used to locate the cystic duct and avoid inadvertant incision or division of the common ducts. Received: 17 March 1997/Accepted: 10 July 1997     

腹腔镜胆囊切除术中胆囊管的处理体会

目的探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy，Lc）中胆囊管的处理方法。方法1997年1月-2005年12月，我院行3100例LC，对不同类型的胆囊管分别采取不同的处理方法：常规中号钛夹处理胆囊管2387例（77．0％），大号钛夹法93例（3．0％），可吸收夹法62例（2．0％），丝线结扎法155例（5．0％），阶梯钛夹法217例（7．0％），圈套器处理法184例（5．9％），因局部炎症较重未找到胆囊管者实施特殊处理2例（0．1％）。结果术后发生胆囊管胆汁漏4例（0．1％），留置腹腔引流管引流，辅以内镜逆行胰胆管造影，分别行鼻胆管引流及内支架引流3周后胆管造影，未见胆汁明显外溢及胆管扩张后拔出引流管，全部患者治愈。结论LC中根据不同胆囊管类型，采取个体化处理方案可减少胆管损伤、胆汁漏等并发症，提高手术成功率。     

胆囊管缝扎法在困难腹腔镜胆囊切除术的应用(附36例报告)

目的探讨"困难胆囊"行腹腔镜胆囊切除术中采用胆囊管缝扎法的安全性及有效性。方法回顾性分析我院自2014年12月至2015年12月收治的困难腹腔镜胆囊切除术使用胆囊管缝扎法处理的36例病人资料,其中急性化脓性胆囊炎伴胆囊周围严重粘连17例,胆囊管结石10例,短胆囊管4例,粗胆囊管4例,Mirizzi综合征1例。结果采用胆囊管缝扎法处理36例均成功施行腹腔镜胆囊切除术,无中转开腹。平均手术时间为(65±25)min,平均住院时间为(6.5±2.0)d,均痊愈出院。无胆管损伤、胆瘘、胃肠道损伤等并发症出现。结论腹腔镜胆囊切除术中采用胆囊管缝扎法在处理"困难胆囊"时,具有更安全有效的作用。     

腹腔镜胆囊切除致胆管损伤5例

目的 探讨LC致胆管损伤的原因。方法 回顾性地分析了开展LC以来遇到的5例胆管损伤的具体原因,总结了防止LC致胆管损伤的几点经验。结果 5例中2例于术中发现,分别行“T”管支架引流和端端吻合“T”管支架引流,痊愈而无后遗症。另3例分别行右肝管空肠Roux-en-Y吻合和肝门腔肠Roux-en-Y吻合,其中2例发生逆行感染。结论 LC致胆管损伤最主要的原因并非是由于解剖异常,人为因素、电凝或电钩的盲目使用才是最主要的原因。     

腹腔镜胆囊切除术时胆囊管嵌顿结石的处理

目的　总结腹腔胆囊切除术 (LC)时处理胆囊管结石嵌顿的经验。　方法　 1997年 7月～ 2 0 0 1年 6月 ,5 8例胆囊管结石嵌顿。先行胆囊管切开取石而后术中胆道造影 ,如发现胆总管结石则联合内镜切石或中转开腹。　结果　 5 8例均取石成功。 5 1例行单纯LC。术中胆道造影示胆总管结石 7例 ,5例行LC术中联合内镜下括约肌切开取石 ,2例中转开腹行胆总管切开取石联合T管引流。无严重并发症发生。　结论　几乎所有胆囊管结石嵌顿都可用胆囊管切开取石的方法完成LC ,并结合术中胆道造影 ,如发现胆总管结石可联合内镜括约肌切开取石。     

腹腔镜胆囊切除术中胆囊床胆管损伤的处理

目的探讨预防及处理腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）时胆囊床胆管（包括右肝管分支及迷走胆管）损伤的对策。方法回顾性分析1997年1月～2004年12月2032例LC中15例胆囊床胆管损伤的临床特征、处理方法及效果。结果5例为慢性结石性胆囊炎急性发作，10例为慢性结石性萎缩性胆囊炎。8例右肝管分支损伤，7例迷走胆管损伤。8例用钛夹夹闭损伤胆管，5例缝合损伤胆管，另2例由于裂口较大且靠近右肝管主干而行开腹胆管修补术。术后胆漏1例，引流5d后痊愈。随访半年～3年，平均23个月，症状消失，无黄疸及胆管炎等并发症发生。结论预防胆囊床处胆管损伤的关键是紧贴胆囊壁剥离胆囊，术中及时发现并采用恰当的处理方法可获得较好的结果。