Management of bile leaks following laparoscopic cholecystectomy

Summary In a series of 650 consecutive laparoscopic cholecystectomies, nine bile leaks were identified (1.4%). Patients with bile leaks presented clinically at a mean of 4.9 days (range: 3–8 days) after surgery complaining of diffuse abdominal pain, ileus, and nausea. Laboratory values for complete blood counts and liver function tests were all mildly elevated. Definitive diagnosis was made on the basis of abnormal hepatobiliary scintigraphy. Management strategies included laparotomy and drain placement (n=1), laparoscopy and drain placement (n=3), ERCP and drainage (n=4), and CT-guided percutaneous drainage (n=1). When the etiology of the leakage was identified, it was most commonly either dysfunction of the cystic duct clips (n=3) or leakage from a disrupted duct of Luschka (n=2). The source of the remaining leaks (n=4) was never determined. We conclude that bile leaks are an uncommon cause of morbidity following laparoscopic cholecystectomy. Diagnosis can usually be made with nuclear medicine biliary tract scans and a variety of managements alternatives are successful in treating this complication.     

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 leak from the liver bed following laparoscopic cholecystectomy

Intraperitoneal accumulation of bile from accessory bile ducts following cholecystectomy is an uncommon, but well-described, occurrence. It is not unique to laparoscopic cholecystectomy. The presence of accessory channels between the liver and gallbladder has long been recognized by anatomists and surgeons. They are commonly known as the ducts of Luschka. Recognition and treatment of liver bed bile leaks vary. Usually the surgeon can treat this problem without an exploratory celiotomy depending on availability of ERCP or interventional radiology. This article will review clinical diagnosis, radiologic confirmation, and treatment for this complication.     

Laparoscopic cholecystectomy

From November 1990 to April 1994 we attempted laparoscopic cholecystectomy (LC) in 1,788 consecutive patients. The intraoperative findings related to gallbladder's pathology were as following: chronic cholecystitis in 792 patients (44.3%), simple cholecystolithiasis in 760 (42.5%), acute cholecystitis in 98 (5.5%), hydrops in 44 (2.5%), empyema in 38 (2.1%), gangrenous cholecystitis in 12 patients, acalculous cholecystitis in 20 patients, polyps in 11 patients, adenomyomatosis in 9 patients, and gallbladder's carcinoma in 4 patients. Although we had a considerable number of cases with severe inflammation and/or dense adhesions the conversion rate to open surgery was relatively low (2.5%). There was no procedure-related mortality and no common bile duct injury. Postoperative complications occurred in 58 patients (3.2%). Bile leak was present in 19 patients, retained bile duct stones in 8, severe bleeding in 6, mild pancreatitis in 4, pulmonary embolism in 1, cerebral bleeding in 1, wound infection in 6, abdominal wall hematoma in 4, and umbilical incisional hernia in 2; 7 patients presented other minor complications. The mean postoperative hospital stay of our patients was 1.8 days (range 1–12 days). Adequate measures to prevent intraoperative accidents, meticulous technique, and full maintenance of the equipment are among the most important factors in keeping a low conversion and complication rate in the patients undergoing LC.     

腹腔镜胆囊切除术后胆漏的原因分析和防治

目的　探讨腹腔镜胆囊切除术 (laparoscopiccholecystectomy ,LC)后胆漏的原因和防治。　方法　对 1993年 10月～ 2 0 0 3年 10月十年中 36 2 6例腹腔镜胆囊切除术后并发 9例胆漏进行回顾性分析。　结果　 6例经腹腔引流术 ,其中 1例胆囊管残端漏者联合内镜下鼻胆管引流术治疗 ;腹腔镜探查 3例 ,1例胆囊管残端钛夹夹闭不全者在腹腔镜下重新夹闭成功 ,2例胆管损伤者中转开腹。 9例均治愈出院 ,随访 1～ 9年 ,平均 3 7年 ,无胆道并发症发生。　结论　腹腔镜胆囊切除术后胆漏应早期诊断和及时治疗 ,肝下放置引流管有重要价值 ,但关键在预防。     

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     

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland

INTRODUCTION

The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated.

SUBJECTS AND METHODS

A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990–2007).

RESULTS

A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported.

CONCLUSIONS

Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.     

腹腔镜胆囊切除术并发胆漏7例处理体会

目的 探讨腹腔镜胆囊切除术（Laparoscopic cholecystectomy,LC）并发胆漏的原因及处理方法.方法 对我院普外科2011年1月～2012年12月行腹腔镜胆囊切除术938例中并发胆漏7例患者的临床资料进行回顾分析.结果 7例中3例为术中发现胆漏,4例为术后1-4天发现胆漏;胆总管或肝总管损伤3例,Luschka胆管漏2例,另2例胆漏原因未明确,考虑1例为胆囊管残端漏,1例为胆囊床毛细胆管漏;7例均治愈.结论 熟悉胆囊局部解剖及变异,术中仔细观察,不粗暴操作,可有效预防或及时发现胆漏并进行处理,以微创方式行外引流术是解决LC术后胆漏的有效方法.     

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。     

腹腔镜胆囊切除术后并发胆漏11例分析

目的探讨腹腔镜胆囊切除术后并发胆漏的原因、治疗原则及如何降低腹腔镜胆囊切除术后并发胆漏。方法总结并回顾分析腹腔镜胆囊切除术并发胆漏11例患者的临床资料。结果根据胆漏的原因及胆漏量决定治疗方案,所有患者经保守治疗或再次手术治疗均治愈。结论术中应注意解剖变异、操作仔细;术后及时缜密的观察、护理和采取针对性的治疗方法可减少胆漏的发生及避免胆漏后引起严重的并发症。     

Bile causing an acute scrotum immediately after laparoscopic cholecystectomy.

We report our experience with a patient that developed an acute right hemiscrotum immediately after undergoing an uncomplicated laparoscopic cholecystectomy for gallbladder dyskinesia. The etiology of the acute scrotal pain was due to bile which was spilled into the peritoneum after entry into the gallbladder during dissection. The bile obtained access to the right hemiscrotum via a communicating hydrocele. To the best of our knowledge this is the first report of bile causing an acute scrotum following laparoscopic surgery. A review of the current literature on the topic of the postoperative acute scrotum follows our case presentation.     

Features and management of bile leaks after laparoscopic cholecystectomy

Background/purpose Leakage of bile is one of the troublesome complications after laparoscopic cholecystectomy.Methods The present study reviewed our experience with this complication, in order to analyze its characteristics and proper management.Results Postoperative bile leaks occurred in 23 of 1365 patients (1.7%) undergoing laparoscopic cholecystectomy from July 1990 to May 2002, with the policy of routine operative cholangiography and routine drainage of the gallbladder bed. These patients could be divided into four types. In type 1 (17 patients), bile leakage stopped spontaneously within 3 days (subclinical group). In type 2 (3 patients), the leak continued for longer than 3 days but was controlled by an endoscopic nasobiliary drainage (ENBD tube; minor-leakage group). In type 3 (2 patients), bile leakage continued for longer than 3 days and required open repair (major-leakage group). In type 4 (1 patient), bile leakage started several days after surgery (delayed-leakage group).Conclusions It is thought that better understanding of these four types of bile leakage should help in the proper management of this complication.     

Mechanism, management, and prevention of bile duct injury in laparoscopic cholecystectomy

Injury to the bile duct is one of the most serious complications of laparoscopic cholecystectomy. The incidence of bile duct injury during laparoscopic cholecystectomy may be higher than during open cholecystectomy. Most of these injuries occur early in a surgeon’s experience with the new technique. The classical laparoscopic bile duct injury occurs when the common duct is mistaken for the cystic duct; the common bile duct is transected and a part of the extrahepatic biliary system is resected. The bile duct may also be injured by excessive diathermy, resulting in a bile leak or a stricture. Insecure clipping of the cystic duct may also result in bile leakage. If these injuries are not recognized at the time of surgery, they present as bile collections or jaundice postoperatively. ERCP will delineate the exact injury accurately. These injuries are preventable by careful attention to technique and a willingness to convert to open surgery when difficulties are encountered. To minimize the risk to patients, programs of training, proctoring, and accreditation in laparoscopic surgery should be established.     

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。     

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     

A new training device for laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy provides a new approach for gallbladder removal with which most general surgeons are not familiar. Requisites for the safe performance of this procedure are good hand-eye coordination, depth perception, and team cooperation. To aid with problems in depth perception and in the opposing movements caused by the lever principle, a training model was designed in which surgeons may execute a variety of exercises to enhance their motor skills and learn to work cooperatively with two other surgeons before operating on an experimental animal.     

探讨中老年患者腹腔镜胆囊切除术的疗效

目的：探讨中老年患者腹腔镜胆囊切除术的疗效。方法：将2005年1月-2011年12月接受腹腔镜胆囊切除术的468例中老年患者纳入本研究。患者被分成2组：≥70岁（A组）,〈70岁组（B组）。A组又分为3组,年龄在70～74岁为A1组、75～79岁为A2组,980岁为A3组。组间比较采用Mann—WhitneyU和X2检验。结果：ASA评分随年龄的增加而增加（P〈O．001）。手术时间超过1h的患者中≥70岁的有20例,≤69岁的有120例,2组患者的PaC0：和pH值无显著差异（P〉O．05）。≥80岁患者的急性胆囊炎、中转开腹手术及术后并发症的发生率显著高于其他组的患者（P〈O．05）。结论：对于老年患者的腹腔镜手术是安全可行的,不会增加手术风险。对≥80岁患者进行认真筛选,并由经验丰富、技术力量强的团队进行操作,这将有助于减少手术并发症的发生率。     

Bile leakage following laparoscopic cholecystectomy

Surgical Endoscopy -     

腹腔镜胆囊切除胆管合并血管损伤

血管损伤是与腹腔镜胆囊切除胆管损伤相关的严重并发症,其发生率为6.7%～61.1%.损伤最多的是肝右动脉.血管损伤后不一定有症状,但严重者近期表现为肝缺血、坏死,远期可导致胆管狭窄、肝萎缩等.有的患者血管损伤后需行肝切除甚至肝移植治疗,因此对早期发现的血管损伤,必要时应做血管重建.