Page 40 - World Journal of Laparoscopic Surgery

Mohammad Zarin et al

In our setup, On-table cholangiography is not performed RESULTS
routinely while doing laparoscopic cholecystectomy. It is
Out of the total 760 cases that underwent laparoscopic chole-
mainly due to technical difficulty and nonavailability of the
cystectomy bile duct injury was observed in 7 (0.92%)
equipment in most hospitals. In this study, we report the
seven cases (Table 1).
outcome of a series of patients undergone LC without On-
table cholangiography. Partial Injury to CHD
There were 2 (0.26%) cases of partial injury to the common
PATIENTS AND METHODS
bile duct. One case was that of the “Mirizzi syndrome”.
The opening between the Hartman’s pouch and CHD
This study was carried out in surgical “D” ward Khyber
(common hepatic duct) became evident during dissection.
Teaching Hospital, Peshawar from January 2005 to
Hence immediate laparotomy was done and T-tube placed.
December 2008. A total of 760 patients were included in
In the second case, a small spurt occurred from a vessel
this study. Patients of known gallstone disease without
running over the CHD during dissection of dense adhesions
clinically and radiological proven complications (obstructive
in Calot’s triangle, hence diathermy was used to coagulate
jaundice) were subjected to laparoscopic cholecystectomy.
the bleeder. Nothing happened during the operation. The
Patients were admitted through outpatient or emergency
patient recovered well and was discharged home. However,
department. After proper history and examination the
the patient returned with biliary peritonitis after one week,
gallstone diseases was diagnosed by ultrasonography and
ERCP confirmed the leak in CHD. Laparotomy showed a
CT-scan where needed. Patients with complications like
hole at the site where diathermy was used, a T tube was
obstructive jaundice or gallbladder mass were excluded from
placed.
the study. All patients were operated as elective cases with
laparoscopic procedure. Three ports laparoscopic
Partial Injury to CBD
cholecystectomy was performed in majority of the cases
In 2 (0.26%) patients, the partial injury to CBD occurred
while four ports technique was adopted in difficult cases.
due to tenting and both these injuries were detected
Meticulous concentration was adopted for hepatobiliary
peroperatively. The problem was rectified by conversion to
anomalies. On-table cholangiography was performed in none
open surgery and insertion of T-tube.
of the cases. At the completion of procedure biliary tracts
were examined carefully for evidence of evident or potential
Complete Transaction of CBD
damage. They were observed for a day or two and then
were discharged home. They were advised to attend the This occurred in 2 (0.26%) patients. In one, who had a
follow-up clinics at four to six weeks interval. During very small gallbladder (hardly 2 cm), that was buried in the
postoperative course and follow ups, they were looked for liver near porta hepatis. Besides the entire gallbladder was
evidence of bile duct injury (peritonitis, biliary leakage occupied by a large stone. Thus CBD was mistaken for
through drain or biliary fistula). Thus detected cases of bile cystic duct, clipped and divided. The gallbladder which was
duct injury were admitted for further work up. The data densely adherent with the under surface of liver and was
were entered into a proforma and was analyzed and results separated by blunt and sharp dissection using scissors and
were drawn at the completion of study. diathermy hook, and removed. Drain was placed but next

Table 1: Management of complications
Type of injury No. (%) Action taken Result
Partial injury to CBD 2 (0.26%) Laparotomy and T-tube No further complication
Partial injury to CHD 2 (0.26%) Laparotomy and T-tube insertion No further complication
Cholecystohepatic duct leak 1 (0.13%) Drain placed under ultrasound control Leak continued after two weeks
Laparotomy and stitch applied to
the duct
Complete transaction of CBD 2 (0.26%) Hepatojejunostomy/choledochojejunostomy Complete recovery after four
weeks

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