1. Complications at laparoscopic cholecystectomy
PostgraduATE COURSE
the third surgery unit

2. ANATOMY
GB - reservoir of bile, 7-10 cm in length and cm in diameter,
Situated on the inferior surface of the liver, partially covered by peritoneum, between segments 4 and 5.
The GB is divided into four parts: fundus, body, infundibulum, and neck.
Normally, it contains up to 60 ml of fluid, but it may be distended to a capacity as high as 300 ml.

3. ANATOMY
The Hartmann pouch is an outpouching of the wall in the region of the neck.
This pouch varies in size, largely as a result of dilatation or the presence of stones.
A large Hartman pouch may easily obscure the cystic duct within the triangle of Calot.
A double cystic artery may exist in 15% of the population.
An extremely short (< 2 cm) cystic duct may pose a substantial challenge in the dissection and placement of clips during cholecystectomy.

4. ANATOMY
The triangle of Calot is an important landmark whose boundaries include
the CHD medially,
the cystic duct laterally, and
the inferior edge of the liver superiorly.
This triangular space is dissected to allow the surgeon to identify, divide, and ligate the cystic duct and artery.

5. ANATOMY
Accessory hepatic ducts, also known as the ducts of Luschka, connect directly from the hepatic bed to the gallbladder.
When encountered during a laparoscopic cholecystectomy, they should be ligated to prevent a bile leak or a biliary fistula.

6. ANATOMY

7. ANATOMY

8. BAD CLIPPING

9. BEST PRACTICES All ports should be inserted under direct vision
Placing the patient in the reverse Trendelenburg position with the right side up permits gravity to assist in retraction and allows the structures to fall away from the field
The use of a 30° laparoscope is optional but significantly improves visualization
The subxiphoid incision should be made in an oblique manner so it can be extended in case conversion to open cholecystectomy becomes necessary

10. BEST PRACTICES
An additional 5-mm port placed in the left upper quadrant to retract a floppy liver or press down on a very fatty omentum or duodenum may be the key to success in a difficult case
The liver bed should always be re-checked for bleeding before the gallbladder is completely removed
Drains are not routinely placed but may be necessary in the event of
(1) severe acute cholecystitis with significant inflammation,
(2) suspicion of inadequate control of a duct of Luschka, or
The drain may be placed laparoscopically and brought out through the most lateral of the 5-mm ports at the end of the procedure

11. Tricks that can help the surgeon avoiding this potentially serious complication
Avoiding excessive cephalad traction on the gallbladder so as to prevent tenting and misidentification of the CBD as the cystic duct
Before clipping and transection, carefully identifying the cystic duct and artery in the critical view as the only two structures entering the gallbladder
Litigation is much more common after laparoscopic cholecystectomy than after open cholecystectomy, for two apparent reasons:
bile duct injuries are more common with laparoscopic cholecystectomy;
missed intraoperative injuries may be more common in laparoscopic cholecystectomy cases.
Recommendations for the prevention of bile duct injuries include early conversion of laparoscopic cholecystectomy to open cholecystectomy.

12. Complications Trocar/Veress needle injury Hemorrhage
Gall stone spillage
Bile leakage
CBD injury or stricture
Wound infection or abscess

13. WHEN TO CONVERT TO AN OPEN CHOLECYSTECTOMY
Excessive bleeding is encountered
Patient anatomy is unclear
A very large cystic duct is seen (especially if it was normal on ultrasonography); these findings suggest that the surgeon may be in the wrong place
Conversion to an open procedure should not be considered a complication, and the possibility that it will prove necessary or advisable should be discussed with the patient preoperatively.
In most series, conversion rates are higher with emergency operations-15%.
Conversion rate - 5% in elective cases

14. INDEPENDENT PREDICTORS OF CONVERSION- MULTIVARIATE ANALYSIS
male gender,
elevated white blood cell count,
pericholecystic fluid noted on ultrasonography,
diabetes mellitus, and elevated total bilirubin
gallbladder wall thickness exceeding 4 mm,
previous upper abdominal surgery

15. DECISION TO CONVERT As a general rule,
If the junction of the gallbladder and the cystic duct has not been identified within 30 minutes of the start of the procedure,
a laparoscopic cholecystectomy should be converted to an open cholecystectomy.

16. Complications of Procedure
Hasson trocar/Veress needle injury
Intestinal injury may occur during
establishment of abdominal access,
adhesiolysis,
dissection of the gallbladder away from the duodenum or colon.
An injury to the bowel should be repaired with careful one- or two-layer suture closure.
The rates of injury to viscera or vessels from a Hasson trocar or from a Veress needle- 0.2%.

17. Hemorrhage
When a large-vessel injury occurs - conversion to laparotomy.
Excessive bleeding in the region of the triangle of Calot should not be treated laparoscopically - attempts at blind clipping or cauterization usually lead to worsening hemorrhage or hepatic artery injury.
Only if, a bleeding site can be definitely identified and the locations of both the hepatic artery and the CBD are known, bleeding may be controlled with cauterization or clipping.

18. Hemorrhage
Bleeding in the gallbladder bed can usually be controlled by using a spatulated electrocautery device.
If a larger intrahepatic sinus has been entered, hemostatic agents (eg, microfibrillar collagen) can be placed laparoscopically in the liver bed, and pressure can be maintained with a clamp.
The argon plasma coagulator (APC) can be an excellent tool for severe gallbladder fossa oozing that is not responsive to simple electrocauterization.

19. Bile duct injury
The most dreaded complication of laparoscopic cholecystectomy
Incidence of bile duct injury in lap. Choli. ranges from 0.3% to 2.7%.
Biliary tract injuries in open choli %
A major risk factor for bile duct injury is relative inexperience of the surgeon.
Other risk factors are:
aberrant biliary tree anatomy and the presence of
local acute or chronic inflammation.

20. BD injury Bile duct injury may manifest as
bile leak - due to partial or complete BD transection leading to bile leakage into the peritoneum
biliary obstruction - which may be either partial or complete and is secondary to ductal ligation or chronic stricture formation.

21. BD injury – clinical presentations
Intraoperative presentation - BD injury is identified during the procedure - conversion and repair
Delayed presentation - Patients may present 3-7 days after surgery with fever, abdominal pain, anorexia, ileus, ascites, nausea, jaundice
Late-onset stricture - Patients may present months later with abdominal pain and jaundice

22. Management of bile duct injury depends on the degree of injury and the timing of identification
If the injury is identified intraoperatively, the injured duct should be repaired immediately. Most CBD injuries can be primarily repaired over a T-tube, though in some cases, repair may require transfer to a specialized center.
If the injury is identified postoperatively, CT/MRI is indicated to look for collections or ductal dilatation
CholangioMRI- anatomy of BD
Endoscopic retrograde cholangiopancreatography (ERCP) can be used both diagnostically and therapeutically

23. Treatment of BD injury
CT-guided drainage of biloma followed by ERCP with sphincterotomy and stent placement is the treatment of choice for less severe lesions, such as:
minor lacerations of the CBD
duct of Luschka leak,
displaced cystic duct clips
Surgical biliary reconstruction may be necessary in cases of severe bile duct injury

24. Evaluation of patient after LC
When to suspect a problem?
When the patient does not go well p.o.
Physical examination of the abdo- tenderness
Lab investigations: FBC, LFT’s, Amylase
U/S, CT, cholangio MRI

25. Bile leak after LC Possible causes: CBD stone From the cystic duct
Intraductal ascaris

26. Bile leak after LC

27. Treatment- bile leak Sphincterotomy + stent: → 100% resolution
Sphincterotomy alone: →67% resolution
Surgical procedures were needed more in the sphincterotomy alone group

28. CBD injury at LC

29. CBD injury at LC Bismuth postoperative strictures of the BD

30. Postoperative strictures of the bile ducts CBD injury at LC

31. CBD injury at LC Causes Problems of technique
Problems of misidentification
Inexperience (“learning curve”),
Difficult GB, aberrant anatomy
Intra OP:
too much cautery, esp. in Calot triangle
poorly placed clips
cranial traction
Strasberg SM. J Hepatobiliary Pancreat Surg (2002) 9:543–547

32. CBD injury at LC

33. Avoidance of CBD Injury at LC: IOC