Bile duct injury during laparoscopic cholecystectomy Joint Hospital Surgical Grand Round September 2007 Bile duct injury during laparoscopic cholecystectomy Dr. Law Sze Hong Tuen Mun Hospital

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

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)

New type of injury

New type of injury

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%)

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

Main theme Management of bile duct injuries detected intraoperatively Bile leakage detected in the early postoperative period Biliary strictures will not be discussed

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

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)

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

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)

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

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

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

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

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

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

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

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

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

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

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

Investigations These catheters also will be of assistance in the surgical reconstruction Technically difficult in patients with nondilated biliary tree

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

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

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

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%

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)

Presenting symptoms

Distribution of leakage site

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

Conclusion ERCP is a safe and valuable method to detect bile leak and provide treatment

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