Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P<0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P<0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P<0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six. These data suggest routine IOC may offer significant potential advantages in the detection and subsequent correction of these injuries, as well as preventing extension of partial ductal incisions to complete ductal transections. Surgeons must be able to correctly interpret the IOC. Although routine IOC is suggested, careful dissection principles continue to be most important in the prevention of major extrahepatic bile duct injuries during LC.     

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 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     

Biliary tract injury in laparoscopic cholecystectomy: results of a single unit

Background: Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them. Methods: A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures. Results: There were 899 women (74%) and 317 men (26%), with an age range of 13?92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by chol­angio‐enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting. Conclusions: Single‐centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting.     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

Duodenal perforations after laparoscopic cholecystectomy

Duodenal perforations after laparoscopic cholecystectomies are rarely reported. The aim of this study is to focus on this complication and to suggest ways to reduce its occurrence and avoid diagnostic mistakes and therapeutical delays that could be fatal. We reviewed four personal cases and a number of others reported in the literature. Duodenal perforations are caused by improper use of the irrigator-aspirator device when retracting the duodenum, or by electrosurgical and laser burns. A duodenal perforation should be suspected in cases of bile leakage, peritonitis, intraabdominal or retroperitoneal collections, high serum or drainage amylase concentration, absence of bile leakage from the biliary tree, and the existence of a retroduodenal mass. Diagnosis requires a gastrografin upper GI series. Differential diagnosis is mainly with biliary lesions and other causes of peritonitis. Relaparoscopy may require intraoperative upper GI endoscopy or Kocher's duodenal mobilization to detect the perforation. Early diagnosis allows primary repair, usually by laparoscopy. Perforations of the duodenal cap are easier to diagnose and have a better prognosis than those of the descending duodenum. A lumbar abscess is a frequent complication. Received: 27 May 1998/Accepted: 14 September 1998     

Laparoscopic ultrasonography during laparoscopic cholecystectomy

Background: This study assessed the effectiveness of laparoscopic ultrasonography in demonstrating biliary anatomy, confirming suspected pathology, and detecting unsuspected pathology. Methods: Laparoscopic ultrasonography was performed on 48 patients (17 M:31 M) who underwent laparoscopic cholecystectomy. An Aloka 7.5-MHz linear laparoscopic ultrasound transducer was used for scanning. Results: Gallbladder stones were confirmed by laparoscopic ultrasonography in all patients and unsuspected pathology was found in five patients. Two patients were found to have common bile duct stones by laparoscopic ultrasonography and this was confirmed by laparoscopic cholangiography. Laparoscopic ultrasound was found to be helpful during dissection in four patients, particularly in a patient with Mirizzi syndrome. The entire common bile duct was visualized by laparoscopic ultrasonography in 40 patients but was poorly seen in eight patients. The mean time taken for the examination was 9 min (range 4–18 min). Conclusion: Laparoscopic ultrasound is useful during laparoscopic cholecystectomy. Received: 8 November 1995/Accepted: 5 May 1996     

Micropuncture laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. Methods: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. Results: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45–180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. Conclusions: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure. Received: 28 January 1998/Accepted: 7 May 1998     

Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy

Laparoscopic surgery has emerged as the standard of care for the elective operative management of symptomatic gallbladder disease. The surgical literature is now beginning to accumulate sufficient case numbers that more clearly define the associated morbidity of this type of surgery. This article reports an instance of iatrogenic injury to the right muscular hemidiaphragm and subsequent hernia after laparoscopic cholecystectomy. Received: 22 July 1998/Accepted: 13 October 1998     

Jaundice following laparoscopic cholecystectomy

We report the first case of obstructive cholangitis after laparoscopic cholecystectomy, related to intraperitoneal retained gallstones. Received: 19 December 1996/Accepted: 16 May 1997     

Complications of laparoscopic cholecystectomy in Switzerland

Background: We set out to analyze the technical aspects, intraoperative complications, morbidity, and mortality of laparoscopic cholecystectomy in a multi-institutional study representative of Switzerland. Methods: Data were collected from 10,174 patients from 82 surgical services. A total of 353 different parameters per patient were included. Results: We found intraoperative complications in 34.4% of patients and had a conversion rate of 8.2%. This rate was significantly increased in patients with complicated cholelithiasis and in those with previous upper—but not lower—abdominal surgery. In most cases, conversions to open procedures were required because of technical difficulties due to inflammatory changes and/or unclear anatomical findings at the time of operation. Bleeding was a common intraoperative complication, that significantly increased the risk of conversion. Patients with loss of gallstones in the peritoneal cavity had increased rates of abscesses. The rate of common bile duct injuries was 0.31%, but it decreased significantly as the laparoscopic experience of the surgeon increased. The rate of common bile duct injuries was not increased in patients with acute cholecystitis or in the 1.32% of patients undergoing laparoscopic common bile duct exploration. Intraoperative cholangiography did not reduce the risk of common bile duct injuries, but it allowed them to be diagnosed intraoperatively in 75% of patients. Local complications were recorded in 4.79% of patients, and systemic complications were seen in 5.59%. The mortality rate was 0.2%. Conclusions: Although laparoscopic cholecystectomy is a safe procedure, the rate of conversion to open cholecystectomy is still substantial. The conversion rate depends both on the indication and intraoperative complications. There is still a 10.38% morbidity associated with the procedure; however, the incidence of common bile duct injuries, which decreases with growing laparoscopic experience, was relatively low. Received: 14 October 1997/Accepted: 21 January 1998     

Postoperative drowsiness and emetic sequelae correlate to total amount of carbon dioxide used during laparoscopic cholecystectomy

Background: After laparoscopy with carbon dioxide (CO₂) insufflation early postoperative recovery is often complicated with drowsiness and postoperative nausea and vomiting (PONV). Methods: 25 ASA I − II patients undergoing elective laparoscopic cholecystectomy under standardized anaesthesia were studied in a randomized, prospective study. The conventional CO₂ pneumoperitoneum was compared with the mechanical abdominal wall lift (AWL) method with minimal CO₂ insufflation with special reference to postoperative recovery. Results: Postoperative drowsiness was of a significantly longer duration with the conventional method (p < 0.001) compared with the AWL technique. There was a positive correlation with the total amount of CO₂ used and the duration of drowsiness (r = 0.75, p < 0.01). PONV was seen significantly more often in patients with CO₂ insufflation of more than 121 (p < 0.05). Conclusions: Avoiding excessive CO₂ is beneficial for smoother and more uneventful recovery after laparoscopic cholecystectomy. Received: 11 January 1996/Accepted: 29 May 1996     

Abnormal cholangiograms during laparoscopic cholecystectomy

Background: Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. Methods: Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single ``soft' indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more ``soft' indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. Results: In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. Conclusions: The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%). Received: 29 March 1996/Accepted: 29 July 1996     

A prospective comparison of laparoscopic ultrasound vs intraoperative cholangiogram during laparoscopic cholecystectomy

Background: The laparoscopic ultrasound (US) probe provides a new modality for evaluating biliary anatomy during laparoscopic cholecystectomy (LC). Methods: We performed a laparoscopic US examination in 65 patients without suspected common bile duct (CBD) stones prior to the performance of a laparoscopic cholangiogram (IOC). We then compared the cost, time required, surgeon's assessment of difficulty, and interpretations of findings. Results: There was a significant difference in the cost of US versus the cost of IOC ($362 ± 12 versus $665 ± 12; p < 0.05). Surgeons who had performed >10 US (EXP) were compared with those who had performed ≤10 (NOV). There were significant differences between the EXP and NOV groups in ease of examination, visualization of biliary anatomy, and accuracy of measurement of the CBD. Conclusions: The use of laparoscopic US for the accurate evaluation of the CBD and biliary anatomy requires that the surgeon has surpassed the learning curve, which we have defined as having performed >10 US exams. Received: 1 May 1998/Accepted: 21 October 1998     

Selection criteria for laparoscopic cholecystectomy in an ambulatory care setting

Background: The ambulatory care center offers patient convenience and reduced costs after uneventful laparoscopic cholecystectomy. Methods: A prospectively accumulated database of 1,750 cholecystectomies performed by one surgeon in a hospital setting was analyzed to test criteria for ambulatory cholecystectomy. Proposed criteria included age less than 65, absence of upper abdominal operations, and elective operations in healthy patients at low risk for common bile duct stones. Results: Of 1,750 cholecystectomies, only 605 patients met all criteria for outpatient care. Discharge (from the in-hospital setting) was accomplished within 24 h of operation in 92% (first 3 years) and 98% (last 4 years) of selected cases. Only one patient (0.2%, 1/605) was converted to an open procedure; another was readmitted 30 h postoperatively with hemorrhage from the liver bed. Conclusions: Laparoscopic cholecystectomy can be performed safely in an ambulatory care setting, given careful selection and education of patients and documented experience of the surgical team. Received: 1 April 1997/Accepted: 27 May 1997     

Intraperitoneal bile collections after laparoscopic cholecystectomy

Background: Bile leakage is more common after laparoscopic cholecystectomy than after open surgery. In our department, the rate of postoperative bile collections after open surgery is 0.2% vs 0.6% after laparoscopic cholecystectomy. Methods: We studied 13 cases of intraperitoneal bile collection without common bile duct damage drawn from a total of 5,200 laparoscopic cholecystectomies (0.23%). Clinical presentation, symptoms, method of diagnosis, causes, time of diagnosis, correlation of time of diagnosis with definitive treatment, and postoperative results were analyzed. Results: The symptoms appeared between the 5th and 8th postoperative days. They were observed in patients with either chronic or acute cholecystitis. The main causes were misapplication of clips at the cystic duct and open Luschka's duct. Ultrasound failed for early recognition of bile collections. The definitive diagnosis was made by repeat ultrasonography, CAT scan, and ERCP. Conclusion: The ideal treatment in these cases is a minimally invasive procedure, but since the diagnosis is frequently delayed, open surgery is performed in the majority of patients. However, there were no mortalities in this group of patients. Received: 12 November 1998/Accepted: 15 July 1999/Online publication: 29 August 2000     

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.     

Incisional hernias after laparoscopic vs open cholecystectomy

Background: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. Methods: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n= 142) or open cholecystectomy (OC group, n= 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. Results: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. Conclusions: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure. Received: 16 July 1998/Accepted: 27 November 1998     

Delayed diagnosis of malignant tumors missed at laparoscopic cholecystectomy

Background: The aim of this study was to compare the significance of routine examinations prior to laparoscopic cholecystectomy (LC) with intraoperative abdominal investigation. Preoperative evaluation becomes increasingly important when laparoscopic procedures are performed for the removal of gallstones because other intraabdominal diseases may coexist in these patients, mimicking biliary tract disease. Methods: Over the last 6 years, we treated 816 patients with symptomatic cholecystolithiasis using LC. Prior to surgery, routine tests such as upper abdominal ultrasonography, chest radiography, and standard laboratory blood tests were carried out. Results: Despite these routine tests, coexisting colonic cancers escaped detection in four out of 816 cases. This indicates a risk of more ``missed pathologies' during the course of laparoscopic operations compared to standard laparotomy. Conclusion: The risk of missing coexisting diseases during laparoscopic operations has to be minimized by placing additional emphasis on careful evaluation of anamnesis. Physical examination and additional laboratory tests—such as analysis of tumor markers and blood in the stool—combined with complete abdominal ultrasonography, gastroscopy, and/or complete colonoscopy should be performed prior to LC. Received: 6 October 1996/Accepted: 19 February 1997     

Initial results of a prospective trial of outpatient laparoscopic cholecystectomy

Background: Whether or not laparoscopic cholecystectomy may be performed safely as an outpatient procedure is controversial. In 1993, a protocol for outpatient laparoscopic cholecystectomy was instituted to determine the benefits and safety of discharging patients within several hours of surgery. Methods: The initial 60 outpatient laparoscopic cholecystectomies performed by one surgeon in a hospital-based outpatient teaching facility between February 1993 to June 1996 were prospectively studied. Results: Fifty-eight (97%) patients were discharged successfully after an average stay in the recovery room of 3 h. There were no deaths. Two patients required overnight observation and three patients required readmission. Two patients (3%) had cystic duct leak. The average hospital stay for all patients undergoing laparoscopic cholecystectomy at the institution (inpatient and outpatient) decreased from 3.2 to 1.5 days and the average hospital cost decreased from $7,800 to $4,600 during this period. Conclusion: Laparoscopic cholecystectomy in an outpatient setting is safe and cost-effective in healthy patients. Received: 3 April 1997/Accepted: 10 June 1997