The dramatic reality of biliary tract injury during laparoscopic cholecystectomy

Background: Most reports concerning the outcome of patients with biliary tract injury during laparoscopic cholecystectomy come from tertiary referral centers, and results could be very different in the everyday practice of community surgeons. Objective: The objective is to define the presentation, mechanisms, results of treatment, and long-term outcome of biliary tract injuries during laparoscopic cholecystectomy in the setting of a community surgeon's practice. Methods: An anonymous retrospective multicenter survey of 9,959 patients who underwent laparoscopic cholecystectomy was conducted by the Belgian Group for Endoscopic Surgery, composed mainly of community general surgeons. Results: Sixty-five patients with bile duct injury were reported on; the incidence was 0.5%, varying from 0.35 to 1.3% according to the experience of the surgeon. Thirty-four percent of ductal injuries occurred with experienced surgeons, often in association with local predisposing risk factors. Injury occurred in 87% of cases during dissection of the Calot triangle, with severe injury occurring in 46% of patients. Intraoperative cholangiography was performed in 34% of patients and was associated with a significantly improved operative detection rate of injury (68% vs 32%, p= 0.007). Operative detection of injury occurred in 45% of patients; diffuse bile ascitis was encountered postoperatively in 29%. The overall mortality was 9%, the postoperative biliary complication rate 31%, and the reintervention rate 14%. During a median follow-up of 49 months (range, 3–78 months), 20 of the 61 surviving patients (33%) had recurrent biliary strictures. Multivariate analysis demonstrated that the age of the patient (odds ratio: 0.893) and the presence of biliary peritonitis (odds ratio: 0.061) were independent predictive factors for mortality and that the age of the patient (odds ratio: 1.049) and the occurrence of postoperative biliary complications (odds ratio: 0.161) after the initial biliary repair were independent predictive factors for late biliary stricture. Conclusions: Biliary tract injury is associated with significant mortality and complications in the practice of Belgian community surgeons. Intraoperative detection of ductal injury by the routine use and a correct interpretation of intraoperative cholangiography improved outcome. The impact of the primary biliary repair on long-term outcome is an argument to refer these patients to specialized multidisciplinary experts. The results highlight the importance of surgical experience, proper selection of patients for laparoscopic cholecystectomy, and conversion to laparotomy in difficult cases.