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Common Bile Duct Injury in Laparoscopic Cholecystectomy: Inherent Risk of Procedure or Medical Negligence—A Case Report

associated pancreatitis was made. Computerized Tomography of patient. A doctor is not liable if he exercises reasonable skill
of abdomen did not reveal any leakage from the T tube as the and care, provided that his judgment conforms to accepted
dye was passing smoothly from CBD into duodenal loop without medical practice and does not result in an error of omission.
any extravasation. Patient was kept on intravenous fluids, The doctor cannot be sued for professional negligence, when
antibiotics, vasopressor support and was placed on ventilator. statistics show that accepted methods of treatment have been
Central line was inserted. Blood was sent for culture and employed on the patient and that the risk and injury which
sensitivity test, Serum amylase and serum lipase. ECG and resulted are of a kind that may occur even though reasonable
X-rays were done. Arterial Blood Gas analysis showed severe care has been taken.
metabolic acidosis. In the present case, the patient was admitted with diagnosis
The investigations revealed deranged clotting parameters of acute cholecystitis. Laparoscopic cholecystectomy, which
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and high level of serum amylase and serum lipase. A is the treatment of choice for gallbladder diseases was per-
vasopressin infusion was started and sodium bicarbonate was formed by the treating surgeon. During the surgical procedure,
administered to correct acidosis. Consultation was sought from injury to common bile duct occurred. Bile duct injuries result in
senior nephrologists. Non-contarst Computerized Tomography high morbidity, long-term hospitalization and may be life
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of abdomen was done which was normal. Patient was on dalacin, threatening. The incidence of bile duct injury reported varies
amikacin and vancomycin. The coagulation abnormality was in different studies. Gronroos et al (2003) reported that the risk
corrected with one unit of Fresh Frozen Plasma and one unit of of bile duct injury was 0.86% in total patient population. 2
platelets. He was started on Xigris (Activated Protein C) on Krahenbuhl, et al (2001) reported that overall bile duct injury
fourth postoperative day. Despite these measures the patient’s incidence was 0.3%; 0.18% for symptomatic gallstones, and
condition continued to deteriorate. In the morning hours of the 0.36% for acute cholecystitis .In case of severe chronic chole-
fifth postoperative day, the patient developed cardiac arrest. cystitis with shrunken gallbladder incidence was as high as
Cardiopulmonary resuscitation was attempted with adrenaline, 3% Calvete et al (2000) reported that overall incidence of bile
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atropine and sodium bicarbonate but was unsuccessful and duct injury was 1.4% and Huang , et al (1997) reported that bile
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the patient was declared dead. duct injury accounted for 0.32%. 7
The relatives of the deceased lodged a complaint at the Richardson, et al (1996) has mentioned that severe inflam-
police station alleging negligence in the treatment by the mation, aberrant anatomy and poor visualization as contributory
doctors. The inquest was conducted by police and autopsy factors for CBD injury. This complication may occur even when
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was performed by the board of doctors. the operating surgeon is well experienced. 5,6,9 Francoeur et al
Autopsy findings revealed stitched wounds on right and (2003) reported that these injuries could not be anticipated and
left side of chest with injection marks (Therapeutic Central as such it is an inherent risk of this procedure thus, it is
Venous Line insertion site), Stitched wound 24 cm in length on unavoidable and uniformly first concerned of surgeon after
anterior abdominal wall (Stitched Surgical Incision), stitched injury is about the patients well being. 9
wound around umbilicus (Therapeutic) and injection marks in The bile duct injury in this case was immediately recognized
both side inguinal and both side cubital fossa. Internally, by the operating surgeon. Injury to common bile duct was
stitched surgical wound on first part of duodenum. CBD was repaired by using T-Tube and converting the procedure of
attached to first part of duodenum. Gallbladder was absent. Gel laparoscopic cholecystectomy to open procedure. Other senior
foam present in gallbladder fossa. Both lungs were congested surgeon was also consulted and involved in operation. The
and edematous. Petechial hemorrhages were seen on surface of procedure adopted was in conformation to that as reported in
lungs and liver. Heart shows subendocardial petechial hemorr- literature. Kienzle (1999) had reported that bile duct injury
5,6
hages. There was no evidence of pericardial, pleural effusion or cannot be considered as malpractice, because it could be intra-
hemoperitoneum. Histopathological examination indicated operatively made out and immediately treated. Carroll et al
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congestion in spleen, fatty change in liver, severe pulmonary (1998) concluded that factors that predisposes to lawsuits
edema and hemorrhage in lungs and acute tubular necrosis of include treatment failures in immediately recognized injuries,
proximal tubules of kidneys. complications that result from delays in diagnosis and
Cause of death was attributed to multiple organ failure due misinterpretation of abnormal cholangiograms. Low et al (1997)
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to septicemia following cholecystectomy. reported that in Germany the main reasons for acceptance of a
case of common bile duct injury in laparoscopic cholecystetomy
DISCUSSION
as malpractice were delay in changing to conventional
Professional negligence is defined as absence of reasonable cholecystectomy, delay revisions, laparoscopic revisions and
care and skill or willful negligence of a medical practitioner in not reverting to conventional cholecystectomy in unclear
the treatment of a patient, which causes bodily injury or death situations. 12

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