Bile duct injuries following laparoscopic cholecystectomy and repair involving lowering of the hilar plate

Abstract

Background: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic cholelithiasis, but is associated with a higher incidence of bile duct injuries than the open approach. We evaluated a multidisciplinary approach for managing these injuries after LC. Materials and Methods: From April 2006 to August 2011, all patients who developed bile duct injury after LC and were treated by the hepatobiliary team of Al-Hada Armed Forces Hospital, Taif, Saudi Arabia were included in our study. If an injury was suspected intraoperatively, intraoperative cholangiography was performed; thereafter, if the injury was confirmed, immediate laparotomy and primary repair or hepaticojejunostomy (H-J) involving lowering of the hilar plate were performed. Injuries occurring postoperatively were treated by endoscopic cholangiopancreatography (ERCP) to diagnose the type of Strasberg injury. Strasberg type A injuries were managed endoscopically, and more advanced cases underwent open surgery. Results: Of 30 females and 18 males (mean age, 45 years; range, 18-90 years), 6 cases of bile duct injuries were discovered intraoperatively. Of these, two were classified as type C and underwent primary repair with internal stenting. The other four were classified as type E and were treated by Roux-en-Y H-J reconstruction. Forty-two cases of bile duct injuries presented postoperatively, including 18 Strasberg type A and 24 Strasberg type E injuries. Type A injuries were treated with ERCP and stenting, and six with endoscopic removal of a retained stone. Of the 28 patients who underwent H-J, 20 underwent the technique involving lowering of the hilar plate. Of these, three subsequently developed anastomotic strictures and were treated with percutaneous transhepatic balloon dilatation. There were no mortalities. The mean follow-up was for 36 months. Conclusion: Early referral to a specialized surgeon and a multidisciplinary approach help manage bile duct injury after LC in all patients with an acceptable low stricture rate.