Laparoscopic bile duct injuries: spectrum at a tertiary-care center

BACKGROUND and PURPOSE: Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries. PATIENTS and METHODS: From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients. RESULTS: Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up. CONCLUSION: The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.     

Laparoscopic bile duct injuries: management at a tertiary liver center

Bile duct injury is a rare but morbid complication of laparoscopic cholecystectomy (LC). This study was undertaken to evaluate the management of 20 patients with bile duct injuries during LC who were referred to a tertiary center with expertise in hepatobiliary surgery and liver transplantation. Sixteen (80%) were female. Mean age was 44 (range 13-70) years. Half of the injuries were distal (Bismuth I), and nearly half were diagnosed at LC. Reoperative repair was attempted in 30 per cent. Mean interval between injury and operation was 6.55 months (range 0 to 36 months). Eighteen patients underwent Roux-en-Y hepaticojejunostomy (HJ). Of the two patients who did not undergo HJ (both Bismuth I), one was treated with transhepatic cholangiography only, and one died of multiorgan failure. There were four minor complications and one late reoperation for stricture. We conclude that bile duct injury after LC is successfully managed in a tertiary center by a hepatobiliary-liver transplant team. Principles of management include anatomic definition of injury, control of sepsis, staged approach involving interventional radiology, and operative techniques refined in liver transplantation including magnification, fine sutures, selective use of internal stent, and liver biopsy.     

Laparoscopic injuries to the bile duct. A cause for concern.

The authors report six patients who had injuries to their common hepatic bile duct at laparoscopic cholecystectomy over a 16-month period. Five of the six complications could be attributed to laser injuries during dissection in the region of Calot's triangle. The authors discuss the possible mechanism of these injuries, their perioperative management, and the methods of surgical reconstruction. The follow-up period ranges from 3 months to 21 months. Liver function parameters and isotope biliary excretion scans are back to normal in all six patients. The potential hazards of laparoscopic surgery demand that extraordinary care be used not only during the actual surgical procedure, but also in the preoperative decision concerning the dissection method to be employed.     

Laparoscopic bile duct injuries. Risk factors, recognition, and repair.

Records of 11 patients undergoing biliary reconstruction after laparoscopic cholecystectomy are reviewed. Ductal injuries resulted from failure to define the anatomy of Calot's triangle. Risk factors include scarring, acute cholecystitis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised.     

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.     

腹腔镜胆道修复重建术治疗腹腔镜胆囊切除术中的胆管损伤

目的腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法修复胆管损伤是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。方法总结分析2002年11月至2012年12月采用腹腔镜修复重建术治疗的11例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中（11／1485,0．74％）。男7例,女4例,平均年龄57．4岁（26～70岁）。其中6例为胆管轻度损伤,5例为高位胆管横断的重度胆管损伤。按刘允怡分类法,11例胆管损伤的损伤类型分别是：I型2例,ⅡA型2例,IIIA型2例,ⅣA型3例,ⅣB型2例。9例胆管损伤在术中发现,另2例在术后2d发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤（UA型）的患者采用镜下缝合修补、T管引流来修复g1例右肝管孔状损伤的患者采用镜下单纯缝合修复;1例胆总管误扎的患者在镜下松解结扎线、胆总管探查、T管引流;1例胆囊床迷走小胆管横断的患者镜下缝扎封闭;1例胆囊颈残余胆漏的患者采用镜下切除残余胆囊、缝扎胆囊管的方法修复;另外5例高位胆管横断伤（肝总管或者左、右肝管横断伤）的患者采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。结果11例胆管损伤（BDI）患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是8．9d（5～15d）。患者均获得随访,随访时间8个月-10年不等。11例患者均无胆管狭窄。有1例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行经内镜逆行性胰胆管造影术检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行经内镜下乳头括约肌切开术后治愈。其余10例患者无胆管炎、胆管狭窄等长期并发症。结论轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。     

腹腔镜胆总管切开取石方法探讨

目的 :探讨腹腔镜下胆总管探查胆道取石的方法。方法 :于腹腔镜下对胆总管结石 4 5例按由简单到复杂 ,由损伤轻到损伤重的原则应用冲洗、挤压及分离钳、胆道镜、改良取石钳取石。结果 :用冲吸法取净结石 3例 ,占 6 .6 % ;挤压和分离钳取净结石 13例 ,占 2 8 9% ;胆道镜取净结石 11例 ,占 2 4 % ;取石钳取净结石 18例 ,占 4 0 %。结论 :腹腔镜下胆总管取石应遵循由简到繁的原则 ,用取石钳取石较为可靠     

腹腔镜下胆总管切开探查在胆管结石中的应用

目的 :总结腹腔镜下胆总管切开探查取石术的临床应用经验 ,探讨其手术方法 ,术中注意事项及临床应用的优缺点。方法 :腹腔镜下胆总管切开取石 ,T管引流或一期缝合。结果 :2 3例胆总管结石手术2 1例成功 ,2例中转开腹。结论 :腹腔镜下胆总管切开取石术应掌握适应证 ,才能使创伤减小 ,康复快且安全。     

Iatrogenic bile duct injuries

During a 25-year period (1959–1984), 42 patients with iatrogenic bile duct damage were referred. Before referral, 11 patients had no attempt at reconstruction, while 31 had undergone 41 operations to repair the damage. At admission, 4 patients had secondary biliary cirrhosis, 1 had portal vein thrombosis, and 1 had sepsis. The entire extrahepatic duct system had been resected in 1 patient, and operative treatment includes 41 patients. Fifty-two operations have been performed, and 34 patients (83%) have had an excellent long-term result, median 13 years. Five patients had 4 operations or more (before and after referral), and 3 are alive in good condition. Various methods of repair were employed, and 8 patients (20%) had recurrence of stricture. Restricture was lowest for hepaticojejunostomy Roux-en-Y (15%), in particular when no stent was used across the anastomosis (8%). The hospital mortality rate was 2 (5%) of 41 and overall mortality, 7 (17%) of 41. The lowest mortality rate (9%) was associated with hepaticojejunostomy Roux-en-Y. Low rate of recurrence and mortality are correlated to early referral. Patients who had restricture or died were referred a median 5 and 7 months, respectively, later than those who did well. Mortality was also related to serious complications at the time of referral and lack of follow-up. Patients with iatrogenic bile duct injury should be referred early to a competent center, where adequate treatment of infection, reconstruction with a hepaticoje-junostomy Roux-en-Y without stenting, and lifelong follow-up can be performed.

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Resumen En el curso de un período de 25 años (1959-1984), fueron referidos 42 pacientes con lesión iatrogénica del conducto biliar. Anterior a la referencia, 11 no habfan sido sometidos a reconstruction, mientras 31 habfan sido sometidos a 41 operaciones para reparar la lesión. En el momento de la admisión, 4 pacientes presentaban cirrosis biliar secundaria, 1 presentaba trombosis de la vena porta, y 1, sepsis. La totalidad del sistema ductal extrahepático había sido resecado en 1 paciente; el tratamiento operatorio fue realizado en los 41 pacientes. Cincuenta y dos operaciones fueron realizadas, y 34 pacientes (83%) han tenido un excelente resultado a largo plazo, en un seguimiento promedio de 13 años. Cinco pacientes recibieron 4 operaciones o más (antes y después de la referencia), y 3 están vivos y en buena conditión. Varios métodos de reparatión han sido empleados; 8 pacientes (20%) desarrollaron recurrencia de la estrechez. La tasa de recurrencia fue más baja para la hepaticoyeyunostomía de Roux-en-Y (15%), particularmente cuando no se utilizó una prótesis a través de la anastomosis (8%). La mortalidad hospitalaria fue de 2 entre 41 casos (5%) y la mortalidad global de 7 entre 41 (17%). La menor mortalidad (9%) se observó en los pacientes sometidos a hepaticoyeyunostomía de Roux-en-Y. Bajas tasas de recurrencia y de mortalidad aparecen correlacionadas con una referencia temprana. Los pacientes con estrechez recurrente y aquellos que murieron, tuvieron una referencia promedio de 5 y 7 meses respectivamente, más tardía que aquella de los pacientes que evolucionaron bien. La mortalidad también aparece relacionada con complicaciones serias en el momento de la referencia y con falta de seguimiento. Los pacientes con lesión iatrogénica del conducto biliar deben ser referidos precozmente a un centro de reconocida competencia, donde se pueda realizar el tratamiento adecuado de la infectión, la reconstrucción mediante hepáticoyeyunostomía de Roux-en-Y sin prótesis intraluminales, y un seguimiento por el resto de la vida del paciente.

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Résumé Pendant une période de 25 ans (1959 à 1984), 42 patients présentant une lésion biliaire iatrogénique ont été adressés aux auteurs. Auparavant, 11 n'avaient subi aucune intervention réparatrice alors que 31 d'entre eux avaient subi une ou plusieurs interventions (41 opérations pour 31 malades). Lors de l'admission, 4 malades présentaient une cirrhose biliaire secondaire, 1 accusait une thrombose de la veine porte, 1 était en proie à une infection. Chez 1 des 41 sujets la totalité de l'arbre biliaire extra-hépatique avait été réséqué. Au total 41 malades sur 42 ont été opérés. Cinquante-deux opérations ont été accomplies. Trente-quatre opérés (83%) ont eu un bon résultat à long terme (médiane: 13 ans), cinq patients ont subi 4 opérations ou plus (avant ou après l'admission), et 3 sont en excellente santé. Différentes opérations reconstructives ont été pratiquées et 8 malades (20%) ont été victimes d'une récidive de la sténose. La nouvelle sténose fut plus rare après hépaticojé-junostomie sur anse en Y à la Roux, en particulier lorsque l'anastomose avait été effectuée sans drain interne (8%). La mortalité hospitalière a été de 5% (2 malades décédés) et la mortalité globale de 17% (7 malades décédés). La mortalité la plus basse (9%) a été observée après hépatico-jéjunostomie. Le taux le plus bas de récidive et de mortalité a été constaté quand le malade a été adressé rapidement, en effet les malades qui ont présenté une récidive ou qui sont morts, ont été reÇus respectivement 5 à 7 mois plus tard après l'origine de la lésion que ceux qui eurent des suites favorables. La mortalité fut fonction aussi de l'existence de complications au moment de l'admission ou de l'absence de suivi après l'intervention initiale. En conclusion, les malades qui sont victimes d'une lésion iatrogénique des voies biliaires doivent Être adressés rapidement à un centre spécialisé ou un traitement adéquat de l'infection, une reconstruction biliaire par hépatico-jéjunostomie sans drain tuteur et un suivi prolongé toute la vie peuvent Être entrepris.

     

Iatrogenic bile duct injuries

Background: The real incidence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is not known. Methods: Using questionnaires, we analyzed 91,232 LC performed by 170 surgical units in Brazil between 1990 and 1997. Results: A total of 167 BDI occurred (0.18%); the most frequent were Bismuth type 1 injuries (67.7%). Most injuries (56.8%) occurred at the hands of surgeons who had surpassed the learning curve (50 operations). However, the incidence dropped with increasing experience; it was 0.77% at surgical departments with <50 operations vs 0.16% at departments with >500 operations. The diagnosis was made intraoperatively in 67.7%, but it was based on intraoperative cholangiography in only 19.5%. The procedure was converted to open surgery in 85.8% when the diagnosis of injury occurred intraoperatively, and laparotomy was performed in 90.7% when the injury was diagnosed postoperatively. The mean hospitalization time was 7.6 ± 5.9 days, the major complications were stenosis and fistulas, and the mortality rate was 4.2%. Conclusion: The incidence of BDI after LC is similar to that reported for the open procedure. BDI increases mortality and morbidity and prolongs hospitalization; therefore, all efforts should be made to reduce its incidence.     

Laparoscopic management of bile duct stones.

Although it may seem that laparoscopic cholecystectomy has revolutionized the way we approach the patient with stones in the gallbladder and bile ducts, only a few rules have really changed. Fluoroscopic cholangiography, a requirement for radiologists and gastroenterologists performing percutaneous transhepatic cholangiography and ERCP, is slowly finding its way into the operating room. No longer is a "palpable stone" a common indication for common bile duct exploration. Most importantly, it is not necessary to make an incision into the bile duct to remove the majority of bile duct stones. The transcystic approach will clear the duct in 85% to 90% of all patients, sparing them extra hospitalization, a T-tube, and the risk of creating a bile duct stricture during sutured closure of the choledochotomy.     

Laparoscopic transcystic common bile duct exploration.

This study reviews the results of transcystic common bile duct exploration (CBDE) for unsuspected stones found during laparoscopic cholecystectomy by a single surgeon in 150 consecutive patients. Fluoroscopic cholangiography was attempted in all but four patients. If the cholangiogram appeared to show common bile duct (CBD) stones, a 5 Fr, 8-mm ureteral stone basket was passed through the cystic duct into the duodenum, opened, and trolled through the CBD. Routine cholangiography was successful in 131 of 144 attempts (90%). An indication for CBDE was found by cholangiogram in seven patients (5%). Two cholangiograms were falsely positive. Stones were removed in five patients. Completion cholangiograms were normal in all patients. One patient developed mild pancreatitis but was discharged 2 days after laparoscopic cholecystectomy. The remainder were discharged on postoperative day 1. One patient was readmitted on postoperative day 2, possibly having passed a retained stone. Fluoroscopic CBDE was successful in clearing the CBD in all patients in this small series and deserves further evaluation.     

Laparoscopic transcystic duct common bile duct exploration

The modern era of common bile duct (CBD) surgery started with Mirizzi, who introduced intraoperative cholangiography in 1932. Intraoperative choledoscopy had been developed as an adjunctive to intraoperative cholangiography, which helped to detect CBD stones in an additional 10% to 15% of instances that otherwise would have been missed. Findings have shown choledochoscopy to be an important technique for efficient and effective management of CBD stones. Efforts to treat patients with common duct stones in one session and to avoid the potential complications of endoscopic sphincterotomy resulted in several laparoscopic transcystic CBD (LTCBDE) techniques. The techniques of transcystic stone extraction include lavage, trolling with wire baskets or biliary balloon catheters, cystic duct dilation, biliary endoscopy, and stone retrieval with wire baskets under direct vision and antegrade sphincterotomy, lithotripsy, and catheter techniques. The indications for LTCBDE are filling or equivocal defects at cholangiography, stones smaller than 10 mm, fewer than 9 stones, and possible tumor. The contraindications are stones larger than 1 cm, stones proximal to the cystic duct entrance into the CBD, small friable cystic duct, and 10 or more stones. Experience with LTCBDE shows that the approach is applicable in more than 85% of cases, with a success rate of 85% to 95%. It also is shown to be more cost effective than postoperative endoscopic retrograde cholangiopancreatography. Recent developments in LTCBDE have focused mainly on implementation of robotically assisted surgery and new imaging methods such as magnetic resonance cholangiopancreatography with three-dimensional virtual cholangioscopy and three-dimensional ultrasound. Further technological advances will facilitate the application of laparoscopic approaches to the common duct, which should become the primary strategy for the great majority of patients.     

腹腔镜再次胆道探查术治疗胆管结石

目的：探讨腹腔镜再次胆道探查术治疗胆管结石的方法和临床应用价值。方法：回顾分析为31例复发性胆管结石患者施行腹腔镜胆道探查取石术的临床资料。结果：31例中2例因腹腔粘连致密,胆道周围组织充血水肿严重而中转开腹。29例完成腹腔镜手术,其中1例因胆总管结石大,1例胆总管下端结石嵌顿,1例肝内胆管结石较多,胆道镜和取石钳取石困难,剑突下切口延长至3~4 cm,直视下用取石钳联合胆道镜取石。行胆总管一期缝合5例,24例行胆总管T管引流术。手术时间平均170 min。术后均无腹腔出血和肠漏等并发症发生。3例出现少量胆漏,未出现腹膜炎和腹内感染征象,腹腔引流管分别于术后第6,9,10天拔除。2例剑突下切口感染均是切口延长者,通过局部换药愈合。胆总管一期缝合5例,术后5~7 d出院。24例行胆总管T管引流的患者中,10例于术后7 d带T管出院,14例于术后14 d夹闭T管后带管出院。术中19例结石取净,10例胆道残余结石患者于术后2个月经胆道镜取出。结论：腹腔镜再次胆道探查术安全,患者创伤小,康复快。胆管炎症严重及肝内外结石较多、胆总管下端结石嵌顿者需慎重选择腹腔镜手术。     

Laparoscopic common bile duct exploration

Surgical Endoscopy -     

Laparoscopic bile duct injury: some myths

Bile duct injury is a serious and feared complication of laparoscopic cholecystectomy. Examination of four frequently repeated statements about this problem in the literature, and in the medico-legal expert reports indicate that these statements are not supported by valid data and, therefore, can be termed 'myths'.