Bile Duct Injuries in the Era of Laparoscopic Cholecystectomies

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Avoiding bile duct injury: “changing the culture of cholecystectomy”

Although bile duct injuries can be repaired with a high level of success and most patients return to preinjury quality of life, it is obvious that prevention is preferable to remediation. In the early days of laparoscopic cholecystectomy, Hunter5 described several techniques to minimize the risk of injury, including the use of a 30° scope, avoidance of electrocautery near the common duct, dissection near the cystic duct-gallbladder junction, and avoidance of dissection of the cystic duct-common

Diagnosis

Recognition and proper diagnosis of bile duct injuries is advantageous in preventing serious complications and obtaining high repair success rates.17 In 10% to 30% of the time, bile duct injuries are recognized at the time of surgery.18, 19 Injuries are suspected or diagnosed when a bile leak is visualized, seen during IOC, or realized after further dissection to clarify the anatomy. Once recognized, the surgeon can assess its severity and determine if there are any associated vascular

Bile Duct Injury

Radiological imaging is extremely useful and is the preferred way to evaluate for the presence of bile duct injury. The initial radiological imaging technique is commonly abdominal ultrasound or computed tomography (CT). Ultrasound and CT are capable of detecting intra-abdominal fluid collections and ductal dilations. Small fluid collections in the gallbladder fossa are found in 10% to 14% of patients after cholecystectomy, and are usually irrelevant.27, 28, 29 However, large fluid collections

Classification

Many classification systems have been proposed to help standardize the description, guide the treatment, and compare the outcomes of biliary injuries. However, no single classification system is universally accepted as the standard. The earliest was proposed by Bismuth and colleagues in 1982. It was designed to categorize strictures according to its anatomic location. Type 1 lesions are low common hepatic duct lesions with a hepatic duct stump greater than 2 cm. Type 2 lesions are proximal

Management

The management of bile duct injuries can be categorized into nonoperative versus operative repairs and early versus delayed repairs. The method and timing of the repair depends on several factors. The extent of the injury, the expertise of the operating surgeon and team, the amount of acute inflammation in the area, and the hemodynamic stability of the patient are the most important factors in achieving a successful repair.20, 23 The timing of the operation, the patient's presenting symptoms,

Outcome

Although endoscopic and surgical results are favorable for bile duct repairs, the patient's qualify of life has been postulated to be affected. deReuver and colleagues64 looked at the longitudinal affects of bile duct injuries on 7 aspects of quality of life. Bile duct injuries have a detrimental effect on generic and disease-specific quality of life. In addition, quality of life did not improve over time. Similar declines in the quality of life were not observed in other studies that showed

Summary

Laparoscopic cholecystectomy has become the standard of care for most gallbladder diseases. Unfortunately, bile duct complication rates for this procedure, although low, have been consistently higher than those of open cholecystectomies, which has resulted in higher rates of morbidity, mortality, and litigation. Bile duct injuries incurred during laparoscopic cholecystectomy are avoidable if the surgeon is vigilant in knowing the risk factors, achieving the critical view of safety, consulting a

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