Cause Of Bile Duct Injury Research Articles

Achieving Critical View of Safety via a New Technique: The Triple One (111) Technique.

Misidentification of anatomical structures is one of the most common causes of bile duct injury following laparoscopic cholecystectomy. Achieving Critical View of Safety (CVS) is a standard step in conducting safe cholecystectomy all over the world. In our institute, we achieve CVS via a unique technique called Triple One or 111 and find it very helpful and easy to achieve CVS. Moreover, the rate of conversion has also decreased while achieving CVS via this technique. The unique aspect of the Triple One technique is that by following this method, even new laparoscopic surgeons can achieve CVS very easily in difficult cases and, hence, it decreases the chances of vasculobiliary injury (VBI). This study aimed to determine how effective the Triple One technique is in achieving CVS as well as in lessening the chances of VBI. A total of 545 patients were admitted through the outpatient department, ranging in age from 30 to 70 years, with a mean of 50 years. The study comprised patients with American Society of Anaesthesiologists (ASA) I & II, acute and chronic cholecystitis, and symptomatic cholelithiasis. The study excluded patients with co-morbidities, prior abdominal procedures, and suspected complications. On the second postoperative day, all patients received their discharge papers and on the seventh postoperative day, follow-up was completed. Successful gallbladder extraction using the Triple One technique was achieved in 540 (99%) cases. The other five (1%) cases converted to open cholecystectomy because of the difficult gallbladder anatomy and extensive scarring. No VBI or bile duct injury was noted. No mortality was recorded during the study period. By incorporating CVS using the Triple One technique into our policies and curriculum, we may encourage safe cholecystectomy practices and prevent bile duct injuries.

Bile leakage from subvesical bile duct (duct of Luschka) after laparoscopic cholecystectomy

Bile leakage is a serious complication in laparoscopic cholecystectomy. Subvesical bile duct (duct of Luschka) injury is a secondary major cause of bile duct injury after laparoscopic cholecystectomy. Between January 2019 and December 2020, we performed 1,269 laparoscopic cholecystectomies in our department. There were 4 cases (0.3%) of subvesical bile duct injury. 1 case was found during operation, the other 3 cases developed abdominal pain after postoperative 3th or 7th days. In the intra-operative case, the injured duct was closed with endo-clip. There was no post-operative complication. Postoperatively found cases were treated with endoscopic retrograde cholagiopanreatography (ERCP). However, ERCP failed (2), continuous bile leak and abdominal pain (1) developed. Re-laparoscopy (2) and explo-laparotomy (1) performed. During operation, meticulous observation of the gallbladder fossa should be performed after cholecystectomy. If bile leak has found post-operatively, ERCP with biliary stenting is effective. If ERCP fails, surgical treatments required. A surgeon should be aware of this anomaly of the bile duct and know about the prevention and the managements.

Bile Duct Injuries During Open and Laparoscopic Cholecystectomy

Abstract Background: Common Bile duct injury after cholecystec-tomy remains one of the most serious iatrogenic catastrophes associated with significant postoperative morbidity and may lead to death after a short period of systemic inflammatory response and multi-organ failure syndrome. Aim of Study: To study the diagnosis and management of bile duct injuries during open and laparoscopic cholecystec-tomy, to avoid further bile duct injuries and its morbidity and mortality. Patients and Methods: This Study was a prospective comparative study on iatrogenic bile duct injury (BDI) after laparoscopic and open cholecystectomy. The cases were performed in the period from April 2015 till February 2018. In which 40 patients with bile duct injuries, 20 after open cholecystectomy (OC) and 20 after laparoscopic cholecystec-tomy (LC) were managed. Results: The number of cases done was 40 patients: 20 patients; 7 (17.5%) males, 13 (32.5%) females post laparo-scopic cholecystectomy, Mean age was 44.3 while overall age range from 25-62 years. 20 patient 9 (22.5%) males, 11 (27.5%) females post open cholecystectomy, Mean age was 42.2 while overall age range from 27-65 years, Fifteen (37.5%) of them associated with diabetes mellitus. Management of BDI after open cholecystectomy was one conservatively, 14 by ERCP with stent, 3 by hepaticojejunos-tomy and 2 by Choledochojejunostomy. After laparoscopic cholecystectomy were managed 2 conservatively, 12 by ERCP and 6 by hepaticojejunostomy. Conclusion: CBD injury complication with early diagnosis and prompt treatment can save patient's life with subsequent few or no complication even after its reconstructive surgery. Training must be emphasized to find all possible ways of recognizing biliary tract anatomy during surgery and possess skills to overwhelm the primary and leading cause of bile duct injury i.e. the visual misperception.

Outcomes of surgery for post-cholecystectomy bile duct injuries: An audit from a tertiary referral center.

Bile duct injury (BDI) after cholecystectomy is a serious complication. It often requires surgical repair. The aim of this study was to report on the short and long-term outcomes of surgery for post-cholecystectomy BDI. All the patients, who underwent surgery for post-cholecystectomy BDI between August 2007 and September 2017, were retrospectively reviewed. McDonald grading system was used to assess the long-term outcome. The risk factors for unsatisfactory long-term outcome were analyzed by univariate and multivatiate logistic regression analysis. In total, 228 patients had a Roux-en-Y hepaticojejunostomy. Open cholecystectomy was the major cause of BDI (61%). The median time from injury to definitive repair was 6 months. The types of BDI were as follows: E1 in 13 (5.7%), E2 in 68 (29.82%), E3 in 108 (47.36%), E4 in 28 (12.28%), and E5 in 11 (4.82%) patients respectively. Postoperative morbidity and mortality were 25% and 1.31% respectively. After a median follow-up of 58 months, 90% patients had excellent to good outcome. Recurrent stricture developed in 6 (3%) patients. On multivariate analysis, long injury-repair interval and previous attempt at repair were independent predictors for unsatisfactory long-term outcome. Surgical reconstruction affords excellent to good results for majority of the patients with post-cholecystectomy BDI. As longer delay in definitive repair and previous attempt at repair were associated with unsatisfactory long-term outcome, early referral to a specialized hepatobiliary surgery unit is recommended.

Case report blunt trauma: an uncommon cause of bile duct injury

Disruption of the biliary tree secondary to blunt trauma is a rare cause for extrahepatic bile duct injury ndash It seldom occurs alone hence this type of injury is easily overshadowed by more overt surgical emergencies and may go undiagnosed leading to complications and potentially adverse outcomes in the later course A variety of imaging modalities have been used to varying degrees of success in identifying biliary tree disruption for stable patients but in emergent settings exploratory laparotomy remains the most efficacious means for identifying injury The spectrum of severity ranges from severe ones such as transection or laceration to contusion and hematoma The incidence of bile leaks following hepatobiliary trauma ranges from to depending on the methods used to diagnose the bile leak We present here a rare case with injury to both IHBR and EHBD as a consequence to abdominal trauma

Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy (FALCON trial): study protocol for a multicentre randomised controlled trial

IntroductionMisidentification of the extrahepatic bile duct anatomy during laparoscopic cholecystectomy (LC) is the main cause of bile duct injury. Easier intraoperative recognition of the biliary anatomy may be accomplished by...

Prevention of bile duct injury: the case for incorporating educational theories of expertise.

Over 700,000 laparoscopic cholecystectomies are performed yearly in the US. Despite multiple advantages of laparoscopic surgery, the increased rate of bile duct injury (BDI) compared to the traditional, open approach to cholecystectomy remains problematic. Due to the seriousness of bile duct injury, the time has come for an aggressive educational campaign to better train laparoscopic surgeons in order to reduce the incidence of this life-threatening and expensive complication. We performed a literature review of what is currently known about the causes of bile duct injury during laparoscopic cholecystectomy. Based on these reviews, we identified educational theories of expertise that may be relevant in understanding variable rates of BDI between surgeons. Finally, we applied educational theories of expertise to the problem of BDI in laparoscopic cholecystectomy to propose how to develop and design an effective educational approach for the prevention of BDI. Multiple studies demonstrate that the primary causes of BDI during laparoscopic cholecystectomy are non-technical. Additionally, there exists a learning curve in which the rates of BDI are higher in a surgeon's earlier cases compared to later cases and that some surgeons perform laparoscopic cholecystectomy with significantly fewer injuries than others. Educational theories indicate that interventions that optimize novice to expert development require (1) revealing expert knowledge to novices and (2) scaffolding the mental habits of expert-like learners. BDI is an appropriate target for the application of educational theories of expertise. Designing better educational interventions for the prevention of BDI will require uncovering the hidden knowledge of expert surgeons and incorporating the processes of reinvestment and progressive problem solving that are inherent to expert performance.

Mo1455 Extended Left Hepatic Trisectionectomy as a Feasible Surgical Procedure for Advanced Perihilar Cholangiocarcinoma

Objectives: The aim of this study was to clarify the short and long term outcome of extended left hepatic trisectionectomy (LT) for perihilar cholangiocarcinoma. Methods: Patients with perihilar cholangiocarcinoma who underwent LT between January 2000 and October 2010 for perihilar cholangiocarcinoma were analyzed retrospectively. Operative variables, mortality, morbidity, recurrence sites and survival of three groups were compared among LT, right hemihepatectomy (RH) and left hemihepatectomy (LH). Results: A total 203 patients underwent surgical resection for perihilar cholangiocarcinoma, 22 (11%) of whom underwent LT, 79 (39%) underwent RH, and 84 (41%) underwent LH. No mortality occurred, but 17 patients had morbidity. Operative time and blood loss were 655 ± 142 minutes and 2100 ± 1080 ml, respectively. Blood loss in patients with LT was significantly more than in those with LH (2100ml versus 1300ml; P = 0.017). The incidence of Grade IIIa complication in patients with LT was significant higher than RH and LH (P=0.044 and P=0.014), but Grade IIIb and IV complication did not occur in patients with LT. Overall 5-year survival rate was 40% with median survival of 45.8 years. There was no significant difference in survival in patients between LT and other two procedures. Conclusions: LT for perihilar cholangiocarcinoma is feasible and can provide a comparable prognosis for advanced perihilar cholangiocarcinoma originating from left hepatic duct or segment 4 especially extending to the root of the right anterior portal pedicle or confluence of the anterior and posterior branch of the bile duct. S-1069 SSAT Abstracts Mo1456 Audit of the use of Critical View of Safety and Infundibular Cystic Technique in Cystic Duct Identification in Laparoscopic Cholecystectomy Anokha Oomman, Ashraf M. Rasheed, Karthic Rajaram, Krithika Murugan Introduction: The commonest cause of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is the confusion of bile duct with cystic duct. Operation notes must include the anatomical rationale by which the cystic duct was conclusively identified. Aim: To examine the quality of documentation and the terms used to describe the method/methods utilised to identify the cystic duct during laparoscopic cholecystectomy. Method: The documentation of the method/s used for cystic duct identification was examined in 322 consecutive nonconverted LCs that were carried out between the months of August 2010 and January 2011. Non-protocolised operation notes were studied and stratified into different groups according to the descriptive terms used. The strata included: 1). No documentation of the method used, 2). Calot's triangle was dissected or demonstrated, 3) Infundibular or infundibulocystic technique used, 4). Critical view of safety (CVS) demonstrated, 5) Intra-operative cholangiogram used, or 6) Other methods. Results: Demonstration of the critical view of safety was documented in (4/310) 1.3% of the cases. Infundibular or infundibulo-cystic technique was used to define the cystic duct in (9/310) 3.4% of the notes. Calot's triangle was mentioned in (255/310) 82.3% of the notes. In (43/310) 13.9% of cases, the cystic artery and duct were mentioned without any reference to critical view of safety, infundibular / infundibulo-cystic technique or Calot's triangle. Conclusion: Written documentation of the method of cystic duct identification in the operation notes during LC is sub-optimal. We, hence recommend standardization of the cholecystectomy operative report, inclusion of a video clip and/ or photo image using digital information and communication in medicine (DICOM) to complement the textual operation notes and move towards structured computerised input that links to the picture archiving and communication system (PACS).

Evaluation and Treatment of Biliary Leaks after Gastrointestinal Surgery

IntroductionSince the introduction of laparoscopic cholecystectomy more than two decades ago, the incidence of bile duct injury has remained greater than that established during the era of open cholecystectomy. DiscussionThis article reviews the common causes of bile duct injury during laparoscopic cholecystectomy and makes recommendations that should help prevent these serious injuries from occurring. ConclusionsThe incidence of bile duct injury during laparoscopic cholecystectomy, although greater than during open cholecystectomy, can be minimized using specific operative strategies and dissection principles.

Prevention of Biliary Leaks

IntroductionSince the introduction of laparoscopic cholecystectomy more than two decades ago, the incidence of bile duct injury has remained greater than that established during the era of open cholecystectomy. DiscussionThis article reviews the common causes of bile duct injury during laparoscopic cholecystectomy and makes recommendations that should help prevent these serious injuries from occurring. ConclusionsThe incidence of bile duct injury during laparoscopic cholecystectomy, although greater than during open cholecystectomy, can be minimized using specific operative strategies and dissection principles.

A survey of bile duct injuries sustained during laparoscopic cholecystectomy

To summarize the reasons for bile duct injury (BDI) after laparoscopic cholecystectomy (LC), and to determine the effect of multiple treatment after BDI. A retrospective cohort study was performed. The medical records of 110 patients diagnosed with BDI after LC from October 1993 to November 2007, in ten large hospitals in Guangdong of China, were reviewed. Among 110 patients with BDI, 58 cases (52.7%) were local patients, whereas 52 cases (47.3%) were transferred from outside hospitals. Reasons for BDI following LC were: (1) Lack of experience of the LC operator (48.2%); (2) LC performed during acute cholecystitis (20.0%); (3) The structure of Calot triangle was unclear (15.5%); (4) Variable anatomical position (11.8%); (5) Intra-operation bleeding (4.5%). The commonest sites of injury were the choledochus and common hepatic duct (76.4%). Following BDI, endoscopic stenting or operative repair was performed in 106 patients. The overall success rate was 95.3% (101/106), with a mortality rate was 0.9% (1/106). Cholangitis occurred in 3.8% (4/106) cases. Choledocho-enterostomy operation was performed in almost 60.0% (63/106) cases, and the success rate was 93.7% (59/63). Endoscopic stenting or operative repair was performed immediately following BDI in 23.6% (25/106) patients, the success rate was 100%; and within 30 days in 63.2% (67/106) patients. Eighty-eight out of 106 patients who underwent repair were successful following the first operative procedure. Factors such as an un-experienced operator and unclear anatomical position were causes of BDI following LC. Early operative repair should be regarded as the treatment of choice, in patients diagnosed with BDI. Early refer to an experienced hepatobiliary operator ensures a high success rate.

Inferior Vena Cava Compression Due to Biloma: A Case Report

Purpose: Biloma is an uncommon but well known complication of cholecystectomy. It varies in sizes from very small inconsequential leaks to very large collections causing pressure symptoms such as in gastric outlet obstruction. However, biloma causing inferior vena cava compression leading to significant edema has not been reported so far. Case Report: We report the case of a 55 year old female presenting with abdominal distention and lower extremity edema, a month after an open cholecystectomy. Physical examination showed distended abdomen with hepatomegaly and pitting edema of bilateral lower extremities. Laboratory data revealed normal hepatic function test except for an elevated alkaline phosphatase. Contrast enhanced computed axial tomography scan (CAT scan) of the abdomen revealed a 15 cm × 20 cm fluid collection (open arrows) displacing the liver far to the left and compressing on the inferior vena cava (closed arrows). The diagnosis of biloma was established at percutaneous drainage with resolution and relief of her symptoms. Discussion: Biloma is a localized collection of bile usually from iatrogenic injury. Laparoscopic cholecystectomy is the most common cause of bile duct injury leading to biloma formation although it can also occur spontaneously when gall stones are impacted in the bile ducts leading to disruption. The incidence varies from 0–7%. Other causes include local infection, cholangiocarcinoma, transarterial chemoembolization of hepatic malignancy and endoscopic retrograde cholangiopancreatography. Postoperative biloma commonly manifests within one week after surgery characterized by abdominal pain, fever, vomiting and jaundice. CAT scan and magnetic resonance imaging are superior to ultrasonography. Continuity between fluid collection and biliary tree can be determined by radionuclide cholescintigraphy. Chemical analysis of the aspirate can confirm the diagnosis. Percutaneous drainage is the treatment of choice for large collections otherwise endoscopic sphincterotomy with or without stent placement is usually adequate. Occasionally surgery may be needed for a persistent biloma particularly if infection ensues.[figure1]Figure

EXTRAHEPATIC BILIARY ANATOMY AT LAPAROSCOPIC CHOLECYSTECTOMY: IS ABERRANT ANATOMY IMPORTANT?

The prevention of major duct injury at cholecystectomy relies on the accurate dissection of the cystic duct and artery, and avoidance of major adjacent biliary and vascular structures. Innumerable variations in the anatomy of the extrahepatic biliary tree and associated vasculature have been reported from radiographical and anatomical studies, and are cited as a potential cause of bile duct injury at cholecystectomy. A photographic study of the dissected anatomy of 186 consecutive cholecystectomies was undertaken and each photo analysed to assess the position of the cystic duct and artery, the common bile duct and any anomalous structures. The anatomy in the region of the gallbladder neck was relatively constant. Anatomical variations were uncommon and anomalous ducts were not seen. Vascular variations were the only significant abnormalities found in the present series. Anatomy in the region of the gallbladder neck varies mostly in vascular patterns. Aberrant ducts or duct abnormalities are rarely seen during cholecystectomy hightlighting the principle that careful dissection and identification is the key to safe cholecystectomy.

New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots

Background. Injury to the bile ducts is the most important complication of laparoscopic cholecystectomy (LC), affecting approximately 2000 patients annually in the United States. Traditional surgical teaching fails to provide adequate extrabiliary reference points. A “person approach” of blame and shame (as distinct from a “system approach”) has evidently been unsuccessful in controlling this problem. New strategies are needed. High-reliability organizations such as aviation and the nuclear power industry have well-developed system-based error prevention programs; the application to laparoscopic operations of some principles used in these programs merits evaluation. In addition, some time-honored teaching of steps to safeguard the bile duct needs to be re-examined. Methods. A review of the literature and of 34 cases of bile duct injury referred to the author was carried out. Traditional surgical teaching was evaluated to identify reasons why it has failed to prevent bile duct injury. New extrabiliary reference points were used. Error prevention strategies derived from the aviation and maritime industries were modified for application to LC. These principles have been applied in a prospective study of 2000 successive LCs carried out on 1 surgical unit, including operations by surgical trainees. Results. The literature and case review indicated that misidentification of biliary anatomy was the major cause of bile duct injury and the injury was unrecognized by the operating surgeon in 3 out of 4 cases, suggesting that traditional surgical teaching provides inadequate reference points to prevent duct misidentification, that spatial disorientation analogous to navigation errors occurs, and that systemic factors predisposing to error are present. Several principles used in navigation were applied. “Human factors,” educational principles derived from aviation crew resource management training, were applied. No bile duct injuries occurred in the 2000 LC operations. Eight patients had biliary leakage develop but all recovered without further surgical intervention. Conclusions. Laparoscopic bile duct injury continues to occur at an unacceptable rate. New strategies involving a system approach and using principles adopted by the aviation and maritime industries were applied in 2000 consecutive LCs without bile duct injury. The application in the operating room of commonly taught navigation principles, the use of extrabiliary reference points such as Rouvière's sulcus, and the introduction of human factors education for surgeons reduces the frequency of bile duct injury. (Surgery 2002;132:826-35.)