Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

Ahmad H M Nassar,Hwei Jene Ng

doi:10.1007/s00423-021-02264-z

Ahmad H M Nassar, Hwei Jene Ng

Open Access

https://doi.org/10.1007/s00423-021-02264-z

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Abstract

PurposeThe main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies.MethodsA prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series.ResultsTwenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured.ConclusionLigation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Highlights

The incidence of post-cholecystectomy bile leakage (PCBL) other than from major ductal injury is 0.3–2.7% of patients undergoing laparoscopic cholecystectomy (LC) [1,2,3]
Five thousand six hundred seventy-five patients underwent laparoscopic cholecystectomy performed by a single surgeon or by trainees under on-table supervision between February 1992 and December 2019
Routine display of CVS was only adopted in 2016 as part of a prospective study of the causes of failure to achieve the CVS [12], a review of the operative records of earlier PCBL patients showed that displaying the CVS failed in 14 of 25 LCs (56%) (Table 2)

Summary

Introduction

The incidence of post-cholecystectomy bile leakage (PCBL) other than from major ductal injury is 0.3–2.7% of patients undergoing laparoscopic cholecystectomy (LC) [1,2,3]. The sources of most bile leaks are either the cystic duct stump (Strasberg classification A) or inadvertently injured hepatocystic ducts (HCD) or subvesical ducts (SVD) [3]. This can result in biloma, biliary fistula or in localised or generalised peritonitis. Published studies have addressed the sources of PCBL and their management [1,2,3] but with less emphasis on measures to prevent this complication. The traditional laparoscopic technique utilises metal clips for cystic duct occlusion. These come with their unique set of complications, dislodgement and PCBL is but one [4].

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