Abstract
BackgroundOver the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates. The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct, ductus choledochus and even the gall bladder.Methodsgall bladder fundus was punctured by Veress needle and all the bile was aspirated. The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus.ResultsBetween October 2003 and December 2004, overall 46 patients (of which 9 males) with a mean age of 47 (between 24 and 74) underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis (the thickness of the gall bladder wall was normal) confirmed by pre-operative abdominal ultrasonography in all patients. The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. were documented in 13 cases. One patient was operated for gall bladder polyp (our first case). Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible. None of the patients developed bile duct injury.ConclusionThe number of bile duct injuries related to anatomic misidentification can be decreased and even vanished by using intraoperative methylene blue injection technique into the gall bladder fundus intraoperatively.
Highlights
Over the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis
The gall bladder, cystic duct and ductus choledochus were painted with methylene blue in 43 cases but only the gall bladder and the proximal cystic duct were visualised in 3 cases
In 5 cases operated by the residents, methylene blue leakage from the gall bladder was observed into the abdominal cavity during the removal procedure
Summary
Laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis. When the literature is reviewed, the incidence of bile duct injuries in LC is between 0,3 – 0,6 % [4,6,7,8,9,10,13,14,15], which may be considered an acceptable percentage, may result in secondary biliary cirrhosis with considerable financial burden [6,8,10]. In United States, 600 000 cases of laparoscopic cholecystectomies are performed annually When this number is taken into consideration, it will be clearly understood that the economic problem caused by even small (0,3 – 0,6 %) rates of bile duct injuries, can not be underestimated[1,15]
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