Incidence Of Bile Duct Injury Research Articles

Laparoscopic biliary tract injury: what are the limits of prevention?

At the joint meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Hepato-Pancreatic-Biliary Association in April 2005, the program committee convened a forum on the subject of biliary injuries that occur during laparoscopic cholecystectomy. More than 300 surgeons attended this forum, and the discussion was lively, indicating that this topic still is important to practicing surgeons. The editors of Surgical Endoscopy have agreed to publish the papers from this forum in this issue of the journal [1, 2, 5, 6, 8]. There are two articles on the prevention of biliary injuries during cholecystectomy and there are three papers on methods for diagnosing, evaluating, and treating the problem once it has occurred. The editors are to be commended for agreeing to print these proceedings because, they are written by experts in the field and are very informative to all surgeons who treat patients with biliary tract disease. The questions are (1) How safe can we make laparoscopic cholecystectomy? and (2) How much can we reduce the rate of bile duct injury? The answer to both questions is that laparoscopic cholecystectomy should certainly be as safe as open cholecystectomy, with a comparable or lower incidence of biliary injury. In this commentary, I review the highlights of the presentations at the symposium and present my observations on the issue of biliary injury. Cholecystectomy for gallstone disease is one of the most common procedures performed by general surgeons in North America. The introduction of laparoscopic cholecystectomy in the early 1990s stands out as one of the most significant new developments in the practice of surgery for the past three decades. Not only did it dramatically change the management for one of the most common surgical conditions—cholelithiasis; it also ushered in the new era of minimally invasive or laparoscopic surgery, which has been successfully applied to many other intraabdominal and thoracic disorders. This new procedure was quickly accepted and adopted by patients, referring doctors, and industry. The benefits of the laparoscopic approach were readily apparent and included a shorter hospital stay, a shorter recovery period, decreased postoperative pain, and a quicker return to normal activity. Unfortunately, along the way, it became apparent that an increase in the rate of biliary tract injuries was associated with laparoscopic cholecystectomy. In the 1990s, several groups reported that the incidence of bile duct injuries had risen from 0.1% to 0.3% for open cholecystectomy to 0.4% to 0.6% for the laparoscopic approach, which was a doubling of the incidence [3, 4, 7, 11]. Initially, these data were viewed as a reflection of the learning curve for this procedure. However, over the next two decades, the results did not change. Injuries to the bile duct continue to occur although the current generation of surgeons grew up in the laparoscopic era. Any improvement or reduction in the incidence and frequency of biliary tract injuries during cholecystectomy will come about only as a result of specific instruction and attention to anatomic detail. Continuing education programs for surgeons in practice and good teaching for our residents in training with continued emphasis on proper technique and precautions are key components. The price to pay for the complications of a biliary tract injury is indeed considerable. The morbidity of these complications is reflected in additional procedures and operations, cholangitis, intraabdominal infection, biliary cirrhosis, and, in extreme cases, endstage liver disease and death. Dr. Traverso opened the aforementioned forum with a presentation on the routine use of intraoperative cholangiography (IOC) as a valuable tool for lowering the risk of bile duct injury during cholecystectomy. He emphasized the diverse pattern of the biliary anatomy and the importance of recognizing biliary anomalies and variations. For him, routine IOC is key to identifying Correspondence to: G. M. Larson Editorial

Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy

The incidence of bile duct injury in laparoscopic cholecystectomy is 0.3% to 1.0%. This is higher than the incidence reported for open cholecystectomy (i.e., 0.1-0.2%), and the surgeons all over the world are relentlessly trying to find the ways and means to lower this incidence. Various operating strategies, techniques, and instrumentations such as the 0 degrees telescope, intraoperative cholangiogram, hydrodissection, and peanut gauze dissection have been claimed by various authors to minimize the risk of bile duct injury during cholecystectomy. However, the surgical fraternity agrees that there has been no substitute for meticulous dissection and display of various vital structures near the common bile duct. The authors describe seven anatomic landmarks encountered during laparoscopic cholecystectomy that assist in safe dissection to prevent bile duct and vascular injury. On the basis of their experience, they believe that if surgeons adhere to these landmarks, excellent results can be achieved.

Risk factors for bile duct injury in laparoscopic cholecystectomy: analysis of 49 cases.

Forty-nine bile duct injuries, representing 0.8 per cent of 6076 laparoscopic cholecystectomies performed in the Netherlands in 1990-1992, were reviewed. The aim of the study was to classify the injuries according to severity, to identify possible risk factors contributing to the aetiology of such injuries and to correlate these with the severity of the injury. On the basis of operative findings, bile duct injuries were classified from minor (classes I-IIIa) to extensive with loss of bile duct tissue (IIIb) or localization in the liver hilum (IV). Of 49 injuries, there were 11 in class I, six in class II, ten in class IIIa, 18 in class IIIb and four in class IV. In 16 patients the injury was detected during laparoscopic cholecystectomy and the procedure converted to laparotomy. The duct injury was minor (class I-IIIa) in 14 of these 16 patients. In 20 of the 33 patients in whom identification of the injury was delayed to a second or third operation, more severe types of injury (classes IIIb and IV) were observed. Delayed detection was associated with greater severity (P = 0.002). Of eight patients with histologically proven acute cholecystitis at cholecystectomy, seven suffered severe injury (class IIIb or IV). Surgical experience with laparoscopic cholecystectomy was an important factor in the incidence of bile duct injury.

Bile duct injury in the era of laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach. A review was performed of the English language literature on the management of bile duct injury listed on Medline databases. There is consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. Early detection and repair is associated with an improved outcome, and the minimum standard of care after the recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. Surgery provides the mainstay of treatment, with proximal hepaticojejunostomy Roux en Y being the operation of choice; a selective role for endoscopic or radiological treatment exists. The outcome after bile duct injury remains poor, especially in relation to the initial expectation of the cholecystectomy. Patients are often committed to a decade of follow-up.

Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group.

The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystectomy in the West of Scotland has been audited prospectively over a 5-year period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals submitted prospective data between September 1990 and September 1995. A total of 5913 laparoscopic cholecystectomies were attempted with 98.3 per cent completion of data collection. During this period 37 laparoscopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. Injuries occurred after a median personal experience of 51 (range 3-247) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injuries occurred in 20 of 37 patients, giving an incidence of 0.3 per cent. Five mechanisms for laparoscopic ductal injury were identified, including tenting, confluence and diathermy injuries as well as the classical and variant classical types. Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17. Contributory factors (severe inflammation, aberrant anatomy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy, although the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mechanism of injury may lead to yet further reductions in this complication.

Bile duct injury and bile leakage in laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.

Laparoscopic cholecystectomy.

After laparoscopic cholecystectomy, the patient can expect a hospital stay of < 2 days and a return to work within 2 weeks. The associated operative mortality rate is low at < 0.2 per cent. The increased incidence of bile duct injury with the laparoscopic technique compared with open cholecystectomy is a cause for concern but such injuries should decrease with proper training in laparoscopic surgery. The use of operative cholangiography (whether routine, selective or never) is controversial but there is no evidence that routine cholangiography will prevent major bile duct injury.

Safe laparoscopic cholecystectomy

The February 2004 issue of Surgical Endoscopy published an article by the Gruppo Laparoscopico Romano entitled ‘‘Bile Duct Injuries During Laparoscopic Cholecystectomy: A 1994–2001 Audit on 13,718 Operations in the Area of Rome.’’ The authors analyze different relevant factors which may influence or participate in the incidence of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). The study correctly showed that the 0 optic probably is not suitable for LC because 29 BDIs occurred when this type of instrument was used, compared with 6 BDIs when a 30 optic was used. We, however, note an unusual statement made by the authors in the Results section, namely that the French technique resulted in 27 (81.8%) of the recorded BDIs, whereas the remaining 6 (18.2%) occurred with use of the American technique. The readers are left without any further explanation or conclusion. This statement could, however, mislead young surgeons to believe that LC performed using the French technique carries a fourfold higher rate of BDIs than the American technique. To avoid such a misinterpretation, we think the authors should have informed the readers about how many LCs were performed using each of the two techniques. A short calculation confirms that the French technique is the more widely used in the Rome area. With this technique, the tissue in the triangle of Calot is dissected primarily to visualize the cystic duct and the cystic artery, and to form the first window between these two anatomic structures. The next step is to form a second window by careful dissection between the cystic artery and the gallbladder liver bed. After the anatomy of the triangle of Calot has been assesses carefully from both the anterior and posterior aspects of the gallbladder (‘‘critical view’’), clips can be placed on each of the two structures, which then can be divided safely. Laparoscopic cholecystectomy using the French technique is best adjusted, in our experience as well as that of others, to minimize the risk of causing a BDI. How many LCs have been performed by surgeons in Rome and its provinces using the French technique? According to the authors, the incidence of BDIs was unchanged during the 8-year period (i.e., 0.24%). Whereas 27 French BDIs at a rate of 0.24% represent 11,250 LCs, 6 American BDIs at the same 0.24% rate represent 2,500 LCs. Commendable surgical skill contributes to the high percentage (82%) of LCs performed using the French technique in the Rome area, whereas only 18% were performed using the American technique. In any case, the French operative technique, which ensures the performance of safe LCs, is used by the majority of surgeons in the area of Rome and its provinces. In conclusion, the study showed that there was no difference in the incidence of BDIs between the two techniques.

Bile Duct Injury During Laparoscopic Cholecystectomy

Bile duct injury (BDI) remains the most serious complication of cholecystectomy. With laparoscopic cholecystectomy (LC), the incidence has become more frequent. This study verifies the current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. Anonymous retrospective multicenter survey. Department of surgery at a university referral center, collecting data from general surgical units. Data from 56 591 patients who underwent LC between January 1, 1998, and December 31, 2000, in 184 hospitals in Italy were analyzed. Current incidence, mechanism, presentation, and treatment of BDI occurring during LC in general surgical practice. Two hundred thirty-five BDIs were reported, with an overall incidence of 0.42%. There were no risk factors in 80.0% of the patients. Poor identification of the anatomical features of the hepatic pedicle was the most frequently reported cause (36.8%), and technical problems accounted for 27.0% of causes. The incidence of BDI was higher during cholecystitis (P<.001) and decreased with increasing number of LCs performed by the surgical teams (P<.01). There was no difference in incidence according to technique (French or US) or to routine or selective intraoperative cholangiography. One hundred eight BDIs (46.0%) were recognized intraoperatively and immediately repaired in 89.8% of patients. One hundred twenty-seven BDIs (54.0%) were diagnosed postoperatively, the dominant manifestation being biliary fistula (44.1%). This study confirms a higher incidence of BDI during LC. It highlights the relevance of the number of previously performed LCs and of the correct surgical technique to avoid BDI. The need for correct procedures, adequate expertise of the repairing surgeon in BDI repairs, and a multidisciplinary approach in the management of BDI is emphasized.

Bile Duct Injuries Associated with Laparoscopic and Open Cholecystectomy: An 11-Year Experience in One Institute

Bile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece. Between January 1991 and December 2001, 3637 patients underwent cholecystectomy in our department; as LC in 2079 patients (LC group) and as OC in 1558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons. There were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon. Laparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

Can bile duct injuries be prevented? "A new technique in laparoscopic cholecystectomy"

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.

Isolated Right Segmental Hepatic Duct Injury Following Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. There is an increased incidence of bile duct injuries in LC compared with the open technique. Isolated right segmental hepatic duct injury (IRSHDI) represents a challenge not only for management but also for diagnosis. We present our experience in the management of IRSHDI, with long-term follow-up after treatment by a multidisciplinary approach. Twelve consecutive patients (9 women, mean age 48 years) were identified as having IRSHDI. Patients' demographics, clinical presentation, management and outcome were collected for analysis. The mean follow-up was 44 months (range 2-90 months). Three patients had the LC immediately converted to open surgery without repair of the biliary injury before referral. Treatments before referral included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery, isolated or in combination. The median interval from LC to referral was 32 days. Eleven patients presented with biliary leak and biloma, one with obstruction of an isolated right hepatic segment. Post-referral management of the biliary lesion used a combination of ERCP stenting, percutaneous drainage and stent placement and surgery. In 6 of 12 patients ERCP was the first procedure, and in only one case was IRSHDI identified. In 6 patients, percutaneous transhepatic cholangiography (PTC) was performed first and an isolated right hepatic segment was demonstrated in all. The final treatment modality was endoscopic management and/or percutaneous drainage and stenting in 6 patients, and surgery in 6. The mean follow-up was 44 months. No mortality or significant morbidity was observed. Successful management of IRSHDI after LC requires adequate identification of the lesion, and multidisciplinary treatment is necessary. Half of the patients can be treated successfully by nonsurgical procedures.

Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre.

Mirizzi syndrome is uncommon. It is, however, clinically important, as it is associated with an increased incidence of bile duct injury and demands more complex surgical techniques. A retrospective review of 24 consecutive cases of Mirizzi syndrome that arose between January 1997 and July 2002 was performed. A total of 1881 cholecystectomies were performed during that period. Of the 24 patients, 19 (79.2%) had Mirizzi type I, four (16.7%) had type II, while one (4.2%) had type III disease. Only 54.2% of patients were symptomatic prior to presentation. One-third of patients had normal liver function tests. Ultrasonography and computed tomography were not helpful in diagnosing this entity. Endoscopic retrograde cholangiopancreatography (ERCP) was useful to identify cholecystocholedochal fistulas and to allow therapeutic endoscopic stenting but failed to pick up the syndrome in half of the patients. Inadvertent bile duct injury occurred in four patients (16.7%), all occurred in patients without a preoperative diagnosis. Three of the four injuries occurred during operations by a senior registrar rather than a consultant. Mirizzi type I was managed with either total or subtotal cholecystectomy, while types II and III cases were managed with either T-tube insertion or biliary bypass procedures. Bile duct injury was managed with T-tube successfully in one patient while the rest went on to biliary bypass operations. All except one patient had good functional outcomes on follow up. The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.

Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience.

Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 1.4% incidence of bile duct injuries during laparoscopic cholecystectomy. The aim of this study was to report on an institutional experience with the management of complex bile duct injuries and outcome after surgical repair. Data were collected prospectively from 40 patients with bile duct injuries referred for surgical treatment to our center between April 1998 and December 2003. Prior to referral, 35 patients (87.5%) underwent attempts at surgical reconstruction at the primary hospital. In 77.5% of the patients, complex type E1 or type E2 BDI was found. Concomitant with bile duct injury, seven patients had vascular injuries. Roux-en-Y hepaticojejunostomy was carried out in 33 patients. In two patients, Roux-en-Y hepaticojejunostomy and vascular reconstruction were necessary. Five patients, one with primary nondiagnosed Klatskin tumor, required right hepatectomy. Two patients, both with bile duct injuries and vascular damage, died postoperatively. Because of progressive liver insufficiency, one of them was listed for high-urgency liver transplantation but died prior to intervention. At the median follow-up of 589 days, 82.5% of the patients are in excellent general condition. Seven patients have signs of chronic cholangitis. Major bile duct injuries remain a significant cause of morbidity and even death after laparoscopic cholecystectomy. Because they present a considerable surgical challenge, early referral to an experienced hepatobiliary center is recommended.

Late occlusion of the biliary metal stent in a patient with benign biliary stricture

Introduction: Laparoscopic cholecystectomy has some adventages over open surgery, but the incidence of bile duct injury became more frequent. The resulting biliary strictures can be definitely treated by insertion of multiple plastic stents. The metal stents should be avoided in such cases.

Iatrogenic bile duct injuries.

The real incidence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is not known. Using questionnaires, we analyzed 91,232 LC performed by 170 surgical units in Brazil between 1990 and 1997. A total of 167 BDI occurred (0.18%); the most frequent were Bismuth type 1 injuries (67.7%). Most injuries (56.8%) occurred at the hands of surgeons who had surpassed the learning curve (50 operations). However, the incidence dropped with increasing experience; it was 0.77% at surgical departments with <50 operations vs 0.16% at departments with >500 operations. The diagnosis was made intraoperatively in 67.7%, but it was based on intraoperative cholangiography in only 19.5%. The procedure was converted to open surgery in 85.8% when the diagnosis of injury occurred intraoperatively, and laparotomy was performed in 90.7% when the injury was diagnosed postoperatively. The mean hospitalization time was 7.6 +/- 5.9 days, the major complications were stenosis and fistulas, and the mortality rate was 4.2%. The incidence of BDI after LC is similar to that reported for the open procedure. BDI increases mortality and morbidity and prolongs hospitalization; therefore, all efforts should be made to reduce its incidence.

Surgeons’ anonymous response after bile duct injury during cholecystectomy

Background Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem. Methods A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada. Results Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons’s first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient’s well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy. Conclusions General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective.

To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error. The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations. The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot. These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

Biliary tract injury in laparoscopic cholecystectomy: results of a single unit.

Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them. A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures. There were 899 women (74%) and 317 men (26%), with an age range of 13-92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by chol-angio-enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting. Single-centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting.

Management and outcome of major bile duct injuries after laparoscopic cholecystectomy: from therapeutic endoscopy to liver transplantation.

Laparoscopic cholecystectomy is associated with a higher rate of bile duct injuries than an open cholecystectomy. The annual incidence of bile duct injuries has remained almost constant and these injuries tend to be more serious, making demands on the method of repair. We wanted to report the management and outcome of major bile duct injuries after laparoscopic cholecystectomy in patients referred to a hepatobiliary and liver transplantation unit. Eighteen patients (14 women), with a median age of 53.5 years were referred to the liver surgery unit with a major bile duct injury after laparoscopic cholecystectomy. The injury was identified after a median of 3 days (range, 0 to 25 days) after operation and the median time interval to referral was 79 days (0 to 2270 days). Fourteen patients had undergone surgery before referral. By the time of referral, four patients had developed end-stage cirrhosis, necessitating liver transplantation. Three of them had undergone bilioenteric drainage operations at the referring institute. Of the remaining 14 patients, three were managed by therapeutic endoscopic procedures. Ten patients were managed with Roux-en-Y hepaticojejunostomy. One died of septic complications before the repair. A median time for hospitalization in our unit was 33 days (range, 10 to 164 days). At present, 16 patients are alive. One patient died of Kaposi's sarcoma 7 months after liver transplantation. A long interval between bile duct injury and referral was associated with the development of end-stage liver disease. Surgery of biliary lesions is demanding, and surgical experience with multidisciplinary approach, including therapeutic endoscopy and liver transplantation, is necessary for successful outcome.