Abstract
BackgroundAvulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon. Surgeons are rarely familiar with management of this condition.MethodsPatients with gall stone related problems who were scheduled for LC at the minimal invasive surgery unit of a tertiary referral hospital during a 5 years period (April 2002–April 2007) were prospectively enrolled.Results12 cases were identified (incidence: 1.15%). All 12 patients had gallbladder inflammation. Five patients had acute and seven patients had chronic cholecystitis. The avulsed cystic duct (ACD) was managed by clipping in 4, intracorporeal suturing in 3, converting to open surgery with suture ligation in 2, and lonely external drainage in 3 patients. Bile leakage had ceased within 3 days in 2, 14 days in one, and 20 days in the other patient. Bile volume increased gradually in one of the patients, which stopped only after endoscopic sphincterotomy (ES) at 25th postoperative day. No major late complication or mortality occurred.ConclusionACD during LC is a rare complication. Almost all standard methods of treatment yield to successful outcomes with low morbidity. According to the situation, ACD may be successfully managed laparoscopically. Available cystic stump remnant was clipped. Intracorporeal suture ligation was performed when short length of stump precluded clipping. Deeply retracted cystic duct with active bile leak led to conversion to open surgery. With minimal or no bile leak at ACD stump, closed tube drainage of sub-hepatic area was attempted. Persistent bile leak was assumed to be controlled by ES, successfully accomplished in one patient.
Highlights
Avulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon
The number of bile duct repairs was almost tripled between 1988 and 1992 [5]. It appears that the rate of major injuries to the bile duct following LC is in the range of 0.2 to 0.4 percent, yielding 1000–2000 serious injuries in the USA [6]
Of 1041 LCs performed during the study period, we encountered 12 cases of intraoperative avulsed cystic duct (ACD)
Summary
Avulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon. It has been well established that as LC was gaining popularity, the number of bile duct injuries increased [2-8]. LC usually begins with dissection at gallbladder neck to find cystic duct. In many instances this area is involved with inflammation and adhesion which obscure the anatomical details and predispose the cystic duct to injury during dissection. The traction force would be inevitably transferred to cystic duct and may be more than its tensile strength. After completing the skeletonizing of the duct, the surgeon forgets to reduce the traction force and the duct, devoid of its supporting tissue, is avulsed at the weakest part. Acute inflammation (i.e. acute cholecystitis) may compromise microvascular circulation and lead to relative ischemia, rendering tissues to structural disintegration
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