Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint...
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Transcript of Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint...
![Page 1: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/1.jpg)
Bile duct injury during laparoscopic cholecystectomy
Dr. Law Sze HongTuen Mun Hospital
Joint Hospital Surgical Grand Joint Hospital Surgical Grand
RoundRound
September 2007September 2007
![Page 2: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/2.jpg)
Introduction
Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation
![Page 3: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/3.jpg)
Introduction
Numerous reports have demonstrated that the incidence of bile duct injuries has risen from 0.1-0.2% to 0.4-0.7% between the era of open cholecystectomy and the era of laparoscopic cholecystectomy (Strasberg SM. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101-125)
![Page 4: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/4.jpg)
New type of injury
![Page 5: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/5.jpg)
New type of injury
![Page 6: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/6.jpg)
Prevention
One-third of biliary injuries happen after the surgeon has performed more than 200 cases
Therefore, it is more than inexperience that leads to bile duct injuries
Commonest cause is misidentification of biliary anatomy (70-80%)
![Page 7: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/7.jpg)
Prevention
Hunter and Troidl proposed: 30 degree telescope Avoidance of diathermy close to CHD Dissection close to gallbladder-cystic
junction Conversion to open when uncertain
Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy Am J Surg 1991;162:71-76
Troidl H. Disasters of endoscopic surgery and how to avoid them: error analysis. World J Surg 1999;23:846-855
![Page 8: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/8.jpg)
Main theme
Management of bile duct injuries detected intraoperatively
Bile leakage detected in the early postoperative period
Biliary strictures will not be discussed
![Page 9: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/9.jpg)
Intraoperative management
In general, 75-90% of the injuries are not recognized intraoperatively
Intraoperative identification of injury may occur by recognition of bile in the field, indicating a cut bile duct; by cholangiography; or rarely by direct observation of a divided duct
![Page 10: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/10.jpg)
Role of intraoperative cholangiography (IOC) There is good evidence to show
that intraoperative cholangiography is likely to identify the injury at the time of surgery (Archer SB. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549-559)
Early recognition of biliary injury and appropriate repair is associated with improved outcome (Savader SJ. Laparoscopic cholecystectomy-related bile duct injuries: a health and financial disaster. Ann Surg 1997;225:268-273)
![Page 11: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/11.jpg)
Intraoperative management
If injury to the biliary tree is recognized at the time of initial cholecystectomy, the surgeon should consider his or her experience and ability to repair it immediately
![Page 12: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/12.jpg)
Intraoperative management
Substantial evidence suggests that immediate open conversion and repair by an experienced surgeon is associated with reduced morbidity, shorter duration of illness, and lower cost (Bile duct injuries during laparoscopic cholecystectomy: factors that influence the results of treatment. Stewart L, Way LW. Arch Surg 1995;130:1123-1129)
![Page 13: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/13.jpg)
Intraoperative management Each failed repair is associated with some
loss of bile duct length and greatly exacerbates an already difficult situation
If the surgeon cannot effect a reasonable repair, and competent help is unavailable, drains should be placed to control any biliary leak, and the patient should be referred to a specialist centre
![Page 14: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/14.jpg)
Intraoperative management
In cases of injuries of the biliary tract with minimal tissue loss, primary repair can be performed
Hepaticojejunostomy is required for major duct transection with tissue loss
![Page 15: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/15.jpg)
Intraoperative management
Early recognition of bile duct injury is important as primary repair can be performed at the same operation and in expert hands, the long term outcome is favorable
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Management of bile leak in early postoperative period
Patients with bile leaks generally present within the first week after operation, but some may not become apparent for several weeks
These patients usually present with abdominal pain coupled with fever or other signs of sepsis
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Management of bile leak in early postoperative period
Elevated alkaline phosphatase levels are characteristic, as is hyperbilirubinemia, but jaundice is very uncommon
A few patients present only with vague symptoms such as distension, malaise, anorexia, complaints of discomfort, or requirements for more than the usual amount of analgesia
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Management of bile leak in early postoperative period
Such complaints are all too easy to dismiss, but they might be the only manifestations of a serious biliary injury
Successful management of bile duct injuries recognized in the postoperative period requires thorough investigation and optimal patient preparation
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Investigations Ultrasonography (USG)
An excellent, noninvasive means of showing intrahepatic ductal dilatation and intraperitoneal fluid collection
If a bile collection is suspected, percutaneous aspiration or drain placement can confirm that the fluid is bile and serve as a step to control the effects of the bile leak
![Page 20: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/20.jpg)
Investigations
Computed tomography (CT) Able to show a dilated biliary tree,
identify fluid collections and help localize the level of ductal obstruction in patients with strictures
More sensitive than USG (96% Vs 70%)
Probably the best initial study in biliary injuries
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Investigations
Endoscopic retrograde cholangiopancreatography (ERCP) Has a role in the diagnosis and
treatment of patients with bile leakage from the cystic duct stump or from a laceration of the common duct
Helpful for incomplete strictures
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Investigations Little value in cases of complete
proximal bile duct strictures because there is often discontinuity of the common bile duct preventing visualization of the intrahepatic ductal system
![Page 23: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/23.jpg)
Investigations Percutaneous transhepatic
cholangiography (PTC) Defines the anatomy of the proximal
biliary tree to be used in the surgical reconstruction
Can be followed by placement of percutaneous transhepatic catheters, which can be useful in decompressing the biliary system
![Page 24: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/24.jpg)
Investigations These catheters also will be of
assistance in the surgical reconstruction
Technically difficult in patients with nondilated biliary tree
![Page 25: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/25.jpg)
Optimal patient preparation
Sepsis must be controlled with board-spectrum antibiotics
Intraperitoneal bile collection should be drained
Optimization of nutritional status of the patients ensured
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Management of bile leak in early postoperative period
After thorough investigations and optimal patient preparation, treatment of the biliary injuries can be started
The treatment options will depend on the type of biliary injuries
![Page 27: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/27.jpg)
Management of bile leak in early postoperative period
For biliary leakage from the cystic duct stump, liver bed, or minor lacerations of major bile ducts, reducing intrabiliary pressure by endoscopic sphincterotomy with placement of a stent is usually adequate
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The value of ERCP in patients with bile leak
24 consecutive patients were studied over a 4-year period (2003 – 2006) in Tuen Mun Hospital
A total of 981 laparoscopic cholecystectomies were performed
Incidence: 2%
![Page 29: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/29.jpg)
The value of ERCP in patients with bile leak
The median age of the patients is 55 years (31-77) with no gender difference
ERCP was performed after a median of 4 days postoperatively (3-8 days)
![Page 30: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/30.jpg)
Presenting symptoms
2015
4
Fever Abdominal Pain Cholestasis
![Page 31: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/31.jpg)
Distribution of leakage site
10
33
3
3
2
Cystic Duct Stump leak CHD leak CBD leak
Rt IHD leak Gall bladder bed leak No leak identified
![Page 32: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/32.jpg)
Treatment
All patients (except the two without any leakage site identified with ERCP) were treated successfully with endoscopic sphincterotomy and subsequent stent placement
Follow-up ERCP at 6 weeks showed no more bile leak in all patients
![Page 33: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/33.jpg)
Conclusion
ERCP is a safe and valuable method to detect bile leak and provide treatment
![Page 34: Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital Joint Hospital Surgical Grand Round September 2007.](https://reader033.fdocuments.us/reader033/viewer/2022050920/551b5497550346dd1a8b60f2/html5/thumbnails/34.jpg)
Summary Bile duct injury is a very serious
complication of laparoscopic cholecystectomy
High index of suspicion when patients do not recover uneventfully after laparoscopic cholecystectomy
If biliary injuries occur, seek specialist help