Page 17 - World Journal of Laparoscopic Surgery

BV Sridhar Varma

DISCUSSION to patient’s like less pain, less blood loss during operation,
decreased hospital stay and earlier return to normal activities.
In the recent past laparoscopic cholecystectomy is the gold Inspite of these benefits unfortunately the data of many studies
standard of gall stone diseases, though the impact of CBD show a higher incidence of CBD injuries when compared with
injuries staggering to both patients and health care system. open cholecystectomy (atleast 0.4 to 0.5% vs 0.1 to 0.2%
After reviewing the many articles through internet. I found the respectively). After review of many articles about CBD injuries
so many cases of injuries and the proper management in time regarding risk factor of injuries their proper management and
can decrease the serious complication and mortality. There are long-term detrimental effect of bile duct injury on health and
many factor in laparoscopic cholecystectomy regarding increase quality of life, it is still a gold standard for treatment of
risk of CBD injury: symptomatic gallstone disease uncomplicated gallbladder
1. Misinterpretation of anatomy 70%. diseases like mucocoele, empyma, cholesterosis, porcelain GB,
2. Anatomical variation of Calot’s triangle. adenomatous polyp of GB.
3. Risk factor.
4. Technical errors.
5. Surgeon operates on image rather than reality. RISK FACTOR
6. Anatomical variation and misinterpretation of anatomy. Many studies show that the risk factor increases the chance of
7. GB is the organ having one of the most variable anatomy CBD injury. Many studies like a/population base study of
like. 152776 cholestomoty in sweet disk by Anne Waugh, MD, PhD,
8. Low union with common hepatic duct. Magnus Nilsson, MD, PhD, show that old age, male sex, increase
9. High union with common hepatic duct. the risk of CBD injuries. In the same group the injuries were
10. Adherent to common hepatic duct. three times more, when performed in acute cholecystis compared
11. Cystic duct absent are very short. to elective and even more risk in acute to chronic cholecystitic
12. Anterior spiral joining common hepatic duct left side. when GB is inflamed and fibrosed.
13. Posterior spiral joining common hepatic duct left side.
14. Intrahepatic GB. TECHNICAL ERRORS
15. Aberrant cystic duct.
Surgeons operate on image rather than reality. Visual All the articles like Strasbarg et al in 1995 of more than 124000
psychological studies show that laparoscopic surgeon works Laparoscopic cholecystotomies reported that high rate of billary
on snap interpretation by brain, and success or disasters depend injury was due in part of learning curve effect, as surgeonpassed
on whether snaps are right or wrong. Snap interpretation will be through learning curve have reached, steady-state, there has
wrong if there is eye balldegradation. Lack of initial identification been no significant in the improvement of incident of billary
and memory of the structure to the points of absolute certainty, duct injuries. Major associations have established specific guide
i.e. relative anatomy. Though recall the anatomical variation of lines to avoid this dreaded complication in 1991 Hunter noted
Calot’s triangle but it is more important to remember the relative that bill duct injury in laparoscopic cholecystectomy appear to
anatomy to minimize the risk of CBD injury. Though so many more common in US (0.5 to 2.7%) than in Europe 0.33%. He
articles published regarding preoperative cholangiography observed that American teaching stressed cephalic (towards
regarding the CBD injury like: David R Flum , Thomas Koepsell, the right shoulder) traction of the infundibulum in GB tenting
Patrik Hegarty, et al. Arch Surg 2001:136:1287-92 claiming some the CBD in risking its miss identification. European teaching
decrease risk of CBD injury but in my opinion it is not much stressed the lateral retraction places the cystic duct at right
helpful because surgeon works on relative anatomy rather than angle to CBD reducing the likely hood of miss identification.
absolute anatomy. A little bit advantage of chalcographic is After studying many articles regarding CBD injury in
compensated by the injury to cystic duct during processor and recommendation of guide line for clinical application in laparo-
increase operative time of processor and little risk of injury scopy cholecystectomy by many associations like society of
during procedure itself. Though preoperative cholangiography American gastrointestinal endoscopic surgeons, it is found that:
is helpful in diagnosis of stones in billary duct and to treat them 1. Try to memorize the initial anatomy of Calot’s triangle
in same time.Therefore now, days it is matter of choice from surgeon should concern more about relative anatomy than
center to center to do the intraoperative cholangiography. In initial anatomy.
the same way the high resolution ultrasound preoperatively is 2. Surgeon must clearly identify the cystic duct at its junction
not much helpful because it is not of much help in interpretating with GB.
the billary channel. It can only interpretate bile duct dilatation 3. A large distended GB should be aspirated and lifted rather
and any stone or debris in spite of cost and specialty involving. than grasped.
After the introduction of laparoscopic cholecystecomy in 4. The surgeon should retract the GB infoundibulm laterally
the late decade of 1980, the field of general surgery was rather than in cephalic direction and avoid force fully pulling
revolutionized. After the study of the many articles about up of GB can cause tenting of CBD.
laparoscopic cholecystectomy and bile duct injuries, it was 5. The surgeon should meticulously dissect the cyst duct and
found that laparoscopic cholecystectomy had many benefits cyst artery.

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