Bile Duct Injuries in the Era of Laparoscopic Cholecystectomies
Section snippets
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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Rouviere's sulcus - An anatomical landmark for safe laparoscopic cholecystectomy: A cross-sectional study
2022, Annals of Medicine and SurgeryCitation Excerpt :A safe cholecystectomy is one that is “safe for both the patient (no bile duct/hollow viscus/vascular injury) and for the operating surgeon (no or minimal scope for litigation)” [5,6]. A common landmark or reference point being increasingly described in recent reports is the Rouviere's sulcus (RS) [7]. This sulcus, which was hardly seen or described in the open surgery era, is appreciated very clearly during LC due to the pressure of CO2 insufflation opening up the sulcus widely along with the enhanced illumination and image quality of digital endoscopic cameras used nowadays [8].
Gallstones
2020, Surgery (United Kingdom)Citation Excerpt :Laparoscopic bile duct exploration can be performed in those where ERCP is not possible, for example patients with a large duodenal diverticulum or previous gastric bypass surgery. It is widely held that the incidence of bile duct injuries increased twofold following the introduction of laparoscopic surgery to approximately 0.4%.13 Increasing recognition and the development and promulgation of techniques to prevent BDI has reduced the rates to approximately 0.2–0.3%, however this disguises the fact that there has been a significant increase in more severe BDI including those with an associated vascular injury.
Inside the courtroom: An analysis of malpractice litigation in gallbladder surgery
2020, Surgery (United States)An analysis of early postoperative complications following biliary reconstruction of major bile duct injuries using the Modified Accordion and Anatomic, Timing Of and Mechanism classifications
2019, Surgery Open ScienceCitation Excerpt :Laparoscopic cholecystectomy (LC) is the preferred method of treatment of symptomatic gallstones and offers several advantages over open cholecystectomy, including less postoperative pain, fewer wound infections, shorter hospital stay, earlier return to normal activities and improved cosmetic results [1–3].
Operative Management of Bile Duct Strictures
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2017, Surgery (United Kingdom)