Page 33 - World Association of Laparoscopic Surgeons - Journal

WJOLS
10.5005/jp-journals-10007-1144
Prevention of Common Bile Duct Injuries in Laparoscopic Cholecystectomy
REVIEW ARTICLE
Prevention of Common Bile Duct Injuries in

Laparoscopic Cholecystectomy

Srijan Malla

ABSTRACT indicates that this is still an incompletely resolved
problem. 5,6
Despite advancement in training and technology since its
introduction, more than 20 years ago, bile duct injuries continue The problem is especially highlighted as patients
to be two to three times more common than in open surgery sustaining a bile duct injury (BDI) during cholecystectomy
causing significant morbidity and mortality. Hence, a review of
the literature present on the internet on bile duct injuries in have an impaired quality of life. Bile duct injuries often
laparoscopic cholecystectomy was performed to review the necessitate several invasive procedures and subsequent
causes of biliary injury and methods of prevention of such operations causing fear and anxiety to patients as well as
mishaps. There was a general consensus that careful surgeons. Studies show that such patients continue to have
dissection and correct interpretation of the anatomy avoids
the complication of bile duct injury during cholecystectomy. a higher risk of dying as compared with those who have an
Routine intraoperative cholangiography is associated with a uncomplicated cholecystectomy. 7 There is a significant
lower incidence and early recognition of bile duct injury. A low increase in healthcare expenses associated with the
threshold to conversion to open approach in case of uncertainty
was also advocated. complication and this is a common reason for medical
malpractice litigation.
Keywords: CBD injury, Complication of laparoscopic
cholecystectomy, Common bile duct injury.
AIM
How to cite this article: Malla S. Prevention of Common Bile
Duct Injuries in Laparoscopic Cholecystectomy. World J Lap This article aims to review the causes of biliary injury and
Surg 2012;5(1):27-32. methods of prevention of such mishaps.
Source of support: Nil
MATERIALS AND METHODS
Conflict of interest: None declared
A literature search was performed using internet with
INTRODUCTION medical search engines Pubmed, Medscape using the
keywords—bile duct injuries in laparoscopic
Since its introduction by Erich Muhe in 1985, laparoscopic
cholecystectomy, prevention of bile duct injuries. The
cholecystectomy has gained worldwide acceptance within
articles obtained were then reviewed using the broad
a short period of time to become the gold standard treatment
1
for cholelithiasis. However, along with all the advantages categories of risk factors for BDI, classification of BDI and
methods of prevention.
subsequent upon a minimal invasive procedure, came the
inherent drawbacks of performing surgery in a new and
DISCUSSION
unfamiliar way. The incidence of bile duct injuries were
definitely increased compared with the open technique. 2 Classification of Bile Duct Injuries
Subsequent improvements in the equipment and refinement The traditional Bismuth classification was modified in 1995
in technique, as well as improved training in the by Strasberg et al broadening the details to separately
laparoscopy, resulted in a progressive decrease of the
identify those injuries seen with increased frequency during
incidence of these injuries. Nevertheless, global incidence 2
laparoscopic cholecystectomy (Figs 1A to E5). This
of CBD injury has remained fairly constant around 0.5%, classification, based on anatomic location and severity, is
as reported by various meta-analyses studies over a 15-year widely used currently.
3
period. In the United States, 34 to 49% of surgeons have
caused a major bile duct injury with an individual experience RISK FACTORS FOR BILE DUCT INJURIES
4
of one to two such cases. Increasing evidence suggests that
Training and Experience
such injury should be managed by an experienced
hepatobiliary surgeon and that early recognition of injury Early reports obtained in the 1990s, suggested that the high
directly affects outcome. Furthermore, it continues to be injury rates were due in part to the inexperience in this new
two to three times more common compared with published procedure. This was called the ‘learning curve effect’. 8
major bile duct injury rates for open cholecystectomy which A decrease in the frequency of BDI was therefore expected

World Journal of Laparoscopic Surgery, January-April 2012;5(1):27-32 27