Page 41 - World Journal of Laparoscopic Surgery

Bile Duct Injury in Laparoscopic Cholecystectomy without On-table Cholangiography

day it showed 400 cc of bile which increased in amount On-table cholangiography (OTC) reduces the chances
over the next 48 hours. ERCP confirmed the block in the of bile duct injuries, therefore some authors advocate
CBD. Laparotomy and hepatojejunostomy was performed, routine while other selective cholangiography during LC.
and the patient ultimately recovered. In second patient, this However, due to lack of facility and expertise we perform
disaster happened because of a congenital anomaly (absent LC without OTC. Experience of laparoscopic
cystic duct). Conversion and choledochojejunostomy was cholecystectomy in the United States, where OTC is either
performed. a routine or selectively performed, showed the incidence of
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bile duct injury as 0.6%. MacFadyen BV et al observed
Leak from Cholecystohepatic Duct the incidence of bile duct injury as 0.5%, while Calvete J et
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al. experienced injury rate of 1.3%. In our study, we found
This was realized in a patient who returned on the 4th
the rate of bile duct injuries as 0.92% which is comparable
postoperative day with abdominal distension and pain.
with incidence of centers where OTC is routinely or
Ultrasound showed a huge collection under the liver and
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selectively performed. Archer SB et al in their study also
ultrasound guided drain was placed. As the leakage continued
reported better detection rate of bile duct injuries even without
(around 1000 ml of bile daily), laparotomy was performed
doing OTC.
which revealed a cholecystohepatic duct which was ligated.
The patient recovered uneventfully.
CONCLUSION
DISCUSSION Laparoscopic cholecystectomy can be performed safely
without the use of OTC, provided that pre- and/or
The spectrum of iatrogenic bile duct injuries ranges from
postoperative ERCP is available and performed when
clip impingements to complete transection of the common
indicated.
bile duct. We observed almost all of these injuries in our
study. REFERENCES
It has been previously suggested that the high rate of
1. Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson
biliary injury associated with laparoscopic cholecystectomy RD, Baker ME, et al. Mechanisms of major biliary injury during
is the result of the learning curve. 12,13 However, other laparoscopic cholecystectomy. Ann Surg 1992;215:196-202.
authors have reported it an ongoing problem well beyond 2. Moosa AR, Easter DW, Van Sonnenberg E, Casola G,
the learning period. 14,15 In our study, all the cases were D’Agostino H. Laparoscopic injuries to the bile duct: A cause
for concern. Ann Surg 1992;215:203-08.
performed by experienced laparoscopic surgeons who had
3. Carroll BJ, Friedman RL, Liberman MA, Phillips EH. Routine
already performed more than 100 LC, yet the bile duct cholangiography reduces sequelae of common bile duct injuries.
injuries occurred in 0.92% of cases which indicates that no Surg Endosc 1996;10:1194-97.
surgeon is immune from bile duct injuries during LC. Carroll 4. Mirizzi PL. Operative cholangiography. Surg Gynecol Obstet
16
BJ et al also experienced that most of the injuries occurred 1937;65:702-10.
5. Way LW, Admirand WH, Dunphy JE. Management of
from surgeons who were out of the learning curve. choledocholithiasis. Ann Surg 1972;176:347-59.
In the current study, technical errors were the primary 6. Vezakis A, Davides D, Ammori BJ, Martin IG, Larvin M,
cause of bile duct injuries. In 4 (57.14%) cases, these injuries McMahon MJ. Intraoperative cholangiography during
laparoscopic cholecystectomy. Surg Endosc 2000;14:1118-22.
were the result of misidentification of the anatomy due to
7. Morris JB, Margolis R, Rosato EF. Safe laparoscopic
inadequate dissection and undue tension, resulting in the cholecystectomy without intraoperative cholangiography. Surg
tenting of CBD. While in one case (14.28%), injury occurred Laparosc Endosc 1993;3:17-20.
due to cauterization. Carroll BJ et 16 observed misidenti- 8. Voyles CR, Sanders DL, Hogan R. Common bile duct evaluation
fication of anatomy in 48% cases and cautery injury in 11% in the era of laparoscopic cholecystectomy: 1050 cases later.
Ann Surg 1994;219:744-52.
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of the cases. According to Hunter JG these injuries can
9. Barteau JA, Castro D, Arregui ME, Tetik C. A comparison of
be avoided by the use of a 30° angle forward oblique viewing intraoperative ultrasound versus cholangiography in the
telescope, firm cephalic traction on the fundus and lateral evaluation of the common bile duct during laparoscopic
traction on the infundibulum to place the cystic duct cholecystectomy. Surg Endosc 1995;9:490-96.
10. Cuschieri A, Shimi S, Banting S, Nathanson LK, Pietrabissa A.
perpendicular to the common duct, dissection of the cystic
Intraoperative cholangiography during laparoscopic
duct where it joins the gallbladder, and routine fluoroscopic cholecystectomy. Routine vs selective policy. Surg Endosc
cholangiography. 1994;8:302-05.

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