|
|
|
|
Bile duct injuries in the laparascopic era Abstract: Over past fifteen years, Laparoscopic Cholecystectomy has dramatically altered the management of patients with symptomatic gallstones. Inpatient hospitalization, perioperative pain, and postoperative recovery period have all been dramatically reduced with the introduction of the laparoscopic approach. However, the incidence of iatrogenic biliary injuries has increased with the adoption of laparoscopic cholecystectomy, resulting in considerable morbidity, mortality and malpractice litigation. The majority of laparoscopic bile duct injuries are recognized during the early post operative period and with appropriate management, the long-term results are acceptable. However, with unrecognized or inappropriately managed biliary strictures; recurrent cholangitis, jaundice and even biliary cirrhosis may develop and require additional radiological or surgical procedures with poor outcome and at times leading to mortality. A number of factors have been associated with laparoscopic bile duct injuries. Common factors include chronic inflammation, adhesions in Calot’s triangle, poor exposure and bleeding obscuring the operative field. Laparoscopic Cholecystectomy performed for acute cholecystitis is associated with both a higher conversation rate (29% versus 8%) and a trend towards a higher bile duct injury rate (1.3% versus 0.6%) Surgeon training and experience were recognized as factors in early reports of laparoscopic bile duct injuries. Aberrant biliary anatomy is often cited as a factor in biliary injury. Intraoperatively, several factors have been implicated in biliary injuries. The classic laparoscopic injury occurs when the cystic duct and common bile duct are brought into alignment during the dissection and the common bile duct are brought into alignment during the dissection and the common bile duct which is mistaken for the cystic duct, is isolated, clipped and divided. The other factors include excessive traction on the cystic duct, which can lead to clip placement on the common bile duct, dissecting too deep in the liver parenchyma, which can injure intrahepatic ducts; poor clip placement on the cystic duct; or injudicious use of cautrey. Careful exposure of the structures in the triangle of Calot and clear definition of the gall bladder infundibulum-cystic duct junction prior to dividing any structures should limit the incidence of these injuries. Results of retrospective study with 408 laparostopic cholecystectomies performed by MR SC PATEL and his surgical team in past 10 years at the Aga Khan Hospital, Nairobi have been analysed. There were three minor bile leaks and four major bile leaks leading to bilomas. (1.75%) All three minor bile leaks were successfully treated with ultrasound-guided aspirations. Three major bile leaks (Bilomas turned in to subhepatic abscess and required exploration and drainage of abscess. One large biloma due to lateral diathermal injury to bile duct (0.3%) was treated with exploration of CBD and ‘T’ tube. One case of Biliary stricture from tenting and partial lateral clipping of common Hepatic duct (0.25%) was dealt with choledochojejunostomy with successful outcome. No surgeon is immune from the risk of bile duct injury. Careful surgical technique, early recognition and appropriate management provide the best long-term results.
|
Send mail to
anne.sorvari@sw.ca with
questions or comments about this web site.
|
