Page 10 - Journal of WALS

WJOLS

10.5005/jp-journals-10007-1121
REVIEW ARTICLE Does Timing of Laparoscopic Bile Duct Injury Repair affect Long-term Outcome?
Does Timing of Laparoscopic Bile Duct Injury

Repair affect Long-term Outcome?

Haile M Mezghebe
Surgical Critical Care, Howard University School of Medicine, Georgia Ave NW Ste 4, Washington DC, United Kingdom

ABSTRACT
Objective: This article will review the controversies and prevailing views that deal with the vexing questions of “what is the optimal time
of repair” that delivers the best long-term outcome following laparoscopic surgery injury of bile duct system.
Materials and methods: Literature review conducted using Google search engine and HighWire press, using keywords, like bile duct
injuries, timing of repair, outcome and laparoscopic cholecystectomy.
Results: The reported incidence of bile duct injury after laparoscopic cholecystectomy varies widely due to the inclusion or exclusion
of minor or self-limited events, such as bile leak from intrahepatic radicles or leak from a cystic stump. Once a major bile duct injury
occurs, early recognition is paramount to minimize morbidity and potential mortality. Once recognized, appropriate measures are
instituted to address the damage. However, controversy surrounds as to the optimal time for repair of the injury. The literature gives
conflicting assessment and interpretation of when such injuries should be repaired. Patients cared for in facilities that lack the expertise
to perform immediate repair may inherently end up at a tertiary referral center in a delayed manner. Some recognized institutions and
individual surgeons with the expertise and resources to perform immediate repair opt for repair without delay claiming good outcomes
while others delay the repair to intermediate and late repairs with claims of equally good outcomes reported.
Conclusion: While immediate recognition of any injury is mandatory for improved patient outcome, the timing of repair remains controversial
with convincing arguments on both sides of the issue. However, there seems to be more evidence to support either immediate repair in
experienced hands or delayed repair beyond six weeks. Intermediate repair (within 3 to 14 days) is more likely to lead to failures and
long-term complications.
Keywords: CBD Injury, Common bile duct, Laparoscopic bile duct injury.

INTRODUCTION functional conduit, prevention of fistula, abscess, stricture,

Laparoscopic cholecystectomy (LC) has now been universally cholangitis and secondary biliary cirrhosis.
accepted as the gold standard for symptomatic cholelithiasis.
However, the incidence of bile duct injury is higher compared DISCUSSION
to open cholecystectomy (0.1-0.2% for open and 0.4-0.7%) for Bile duct injury (BDI) following LC has been proposed as the
1-3
LC. These iatrogenic bile duct injuries can have outcomes most serious and important cause of morbidity. 4,5
ranging from minor perioperative morbidity to catastrophic Although the reported incidence is around 0.7%, the true
outcomes with reduced long-term survival, poor quality of life incidence is unknown. It is believed that at least half of all
and even death. practicing general surgeons will encounter one or more bile
There is limited data that addresses the issue of quality of life duct injuries in their life time.
6
after repair of a major bile duct injury. Boerma et al from the Cuschieri identified improper anatomic identification as one
7
Netherlands studied 106 patients who had sustained a variety of of the major causes of BDI and Jin-Shu Wu came to the same
biliary injuries, ranging from cystic duct leaks to major transaction, conclusion by reporting on a large series of patients with CBD
31 of whom were treated surgically and the remaining by non- injury, 60% of which were identified to have had poor
surgical interventions. Despite an overall excellent clinical identification of proper anatomy. The remaining causes were
outcome in the series, quality of life was found to be reduced in related to anatomic variation, poor control of intraoperative
both the physical and psychological aspects (Boerma D, Rauws bleeding, and blind confidence in some. One study
EAJ, Keulemans YLA, et al. Impaired quality of life 5 years after demonstrated that in more than one-third of all bile duct injuries,
bile duct injury during the laparoscopic cholecystectomy: A the basic cause of error is not the inexperience of the surgeon
prospective analysis. Ann Surg 2001;234:750-57). but the use of an improper approach to the fundamental
Management of biliary ductal injuries depends on timely structures of the extra-hepatic biliary tree because of a visual
recognition of the injury, the extent and type of the injury, the perceptual illusion (Br J Surg 1996;83:1356-60).
patient’s co-morbid status and the availability of an experienced Arezou Yaghoubian made indirect reference to surgeon
surgeon. fatigue as a source of increased duct injuries by studying injury
Immediate detection and repair leads to an improved rate at a major US teaching hospital before and after reduction
outcome with the goal of repair being the restoration of a durable of resident work hours. In this study, injury and complication

World Journal of Laparoscopic Surgery, May-August 2011;4(2):81-83 81