Nature, aetiology and outcome of bile duct injuries after laparoscopic cholecystectomy

Abstract

Background Iatrogenic injuries (bile duct, bowel and vascular) have increased substantially since the introduction of laparoscopic cholecystectomy (LC) and have detracted from the overall benefit of this approach. This review is aimed at establishing the trend in the incidence, nature, mechanisms, clinical outcome and financial consequences of bile duct injuries sustained during LC Methods The review is based on a Medline search of the relevant literature from 1986 to 1998. Results Up to 1995, iatrogenic bile duct injuries increased 2–4 fold with an odds ratio (open to laparoscopic) of 1.79. There is some evidence that the incidence has declined in recent years and is related to experience. After 1995 a median incidence rate of 0.3 has been documented in data from retrospective and prospective series. The single most important factor in the aetiology is misinterpretation of the perceived anatomy. Compared to open operation, injuries sustained during LC are more often severe, involving excision of a segment of the common bile duct and extending to higher levels. The majority (70% – 85%) are not recognized during the operation. Combined bile duct and hepatic arterial (right or common hepatic) injuries carry a particularly bad prognosis in terms of postoperative morbidity, mortality and successful outcome after remedial surgery. Bile duct injuries increase substantially the economic burden to the patient, hospital and community. Repair of bile duct injuries cost 4.5 to 26.0 times the cost of an uncomplicated LC and carries a risk of complications and even death. Costs are reduced and outcome improved if injuries are diagnosed early (during operation or the early postoperative period). Delay in diagnosis is the most frequent reason for successful medicolegal litigation. The evidence for and against the value of intraoperative cholangiography in the prevention of bile duct injury remains inconclusive, although it increases the chance of recognition of the injury during operation. The best outcome in the management of LC bile duct injuries is obtained in tertiary referral centres and, increasingly, this necessitates a multidisciplinary approach. Conclusions Bile duct injuries sustained during LC remain a problem, although their incidence appears to be declining in recent years. Most are preventable by ensuring correct interpretation of the displayed anatomy and elective conversion in the presence of anatomical difficulties. A successful outcome after reconstruction is dependent on early recognition, referral to a tertiary centre and the exact nature of the injury.