Master thesis – biology

Surgical Complications from Biliary
Tract Surgery

For a number of years now there has been a significant progress in the development of less invasive surgery. As a result there has been an aggressive increase in the numbers of laparoscopic surgery. Obviously, the relatively shorter hospital recovery stage and the cosmetic appeal of laparoscopic surgery are particularly appealing. Laparoscopic cholecystectomy surgery, however was not intended to accelerate the patient’s discharge from the hospital. Nor was it designed to counter complications associated with the surgery itself. Its primary purpose was and is to eliminate, as far as possible, the discomfort experienced by virtue of surgical incisions.

Although, less invasive that open cholecystectomy, laparoscopic surgery is demanding and involves risks and complications that are not present during the open operative procedure.(1) The New York State department of health investigated the practice of laparoscopic cholecystectomy and identified 158 serious complications associated with the post operative condition of patients undergoing the procedure. Among the complications identified were ‘major vessel laceration, hemorrhage, bile leak and bowel perforation.(2)

On the contrary the New York State department of health identified only 23 complications associated with the post operative condition of patients undergoing open cholecystectomy. In fact ‘the rate of injury to the bile duct was 15 times higher when cholecystectomy was performed laparoscopically than if open cholecystectomy was performed.’(3)

This paper focuses on the incidence of latrogenic bile duct lesions, biliary leakage and major bile duct injuries following laparoscopic cholecystectomy. It also compares the open cholecystectomy with laparoscopic cholecystectomy and examines the methods and studies currently pursued to minimize the complications associated with the laparoscopic procedure.

The following graph is demonstrative of the laparoscopic procedure. (4)


2.1 Introduction
Cholecystectomy is the most common gastro-intestinal operation performed and since the introduction of laparoscopic surgery the number has increased further. Post cholecystectomy syndrome which is seen in as many as 20% cases of gallbladder surgery is manifested by symptoms of pain in the right hypochondrium, vomiting, jaundice, dyspepsia, and fever. Latrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury.

The incidence of biliary lesion following laparoscopic cholecystectomy has been found up to threefold higher than that of open procedure. The trends have changed now and elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystitis and is now proposed for the treatment of acute cholecystitis.

The bile duct is prone to be damaged by use of diathermy and the excessive dissection, required to delineate the anatomy of Calot’s triangle. It often results in ischemic injury to the biliary tract. Other risk factors include difficulty in dissection due to acute or severe chronic inflammation, morbid obesity, unexpected bleeding, and presence of anomalous duct or vessel. These biliary injuries include leaks, strictures and transactions, or ligation of the major bile duct. But various authors have advocated a distinction in bile leaks and bile injuries. The pattern of bile duct injuries has changed and has become more complicated in recent years.

Certain preoperative steps and preoperative techniques have protective effects for these complications. Magnetic resonance cholangiogram is the most sensitive and accurate test for the diagnosis of complications of cholecystectomy although percutaneous transhepatic cholangiography has been considered the preferred investigation. Other investigations in use are ERCP and ultrasonography. Routine intra-operative cholangiography (IOC) may itself also cause bile duct injury if the anatomy in Calot’s triangle is not clear. On the other hand, IOC is helpful for defining anatomy and detecting bile duct stones;
and even preventing, recognizing or decreasing the severity of biliary tract injury. However, still many surgeons do not recommend routine intra-operative cholangiography for fear of injury.

The management of various complications consists of a variety of interventional procedures including simple drainage to stricturoplasty, and others like Roux-en-Y hepaticojejunostomy. So the objective of the study was to find the frequency of different complications, difference in complications in open and laparoscopic chole-cystectomy, investigations done pre- and post-operatively, management of these complications, and its outcome.

2.2 Iatrogenic Bile Duct Injuries (IBDI)
a. The incidence and risk factors of IBDI
It is quite difficult to obtain the exact incidence of IBDI, because bile duct injuries can be caused by the surgeons’ negligence and were sometimes deliberately evaded in the hospital record and they referred those injuries as anatomical abnormalities or agenesis of gall bladder [5]. Huang Xiaoqiang et al collected 39 238 cases of LC from 91 hospitals during the period from April 1991 to November 1995, among them 126 cases were found with bile duct injuries which account for 0.32% [6].

L. Krähenbühl collected 12 111 cases of LC from 84 hospitals in Switzerland during the period from 1995 to 1997 and reported that the incidence
of bile duct injuries (BDI) was 0.3%, in which symptomatic cholecystolithiasis account for 0.1%, acute cholecystitis 0.36% and acute chronic cholecystitis with gallbladder atrophy up to 3% [7]. Wu Xihong reported that 936 cases of MC were performed from January 1998 to November 2000, and the incidence rate of BDI was 0.84% (8/936) [8].

Before LC became common treatment of gall bladder diseases, the number of open cholecystectomy (OC) cases in the US exceeded 700 000 per year and among them the incidence of BDI was 0.2%. [9] Compared to the conventional open cholecystectomy, the incidence of BDI after LC and MC is at least doubled. Many injuries are due, rather, to the surgeon’s failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique.

The increase in frequency of IBDI can not be attributed simply to the inexperience of the surgeons or the learning curve as was initially considered. In the presence of severe acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding and inexperienced surgeon), the surgeons must not hesitate to consider conversion to an open surgical approach.

In such complicated cases, even the open approach is not a guarantee against biliary injury. It must be always remembered that there is no substitute optimization technique for experience and caution in biliary surgery[9,10].

Usually during the procedure of cholecystectomy more emphasis is given to complete exposure of the operating area, to separate the serosa in front of Calot’s triangle, reveal anatomical variations in Calot’s triangle; the cystic duct should not be separated and legated until the junction of the common hepatic and cystic ducts is positively identified, and there is no confluence of any other abnormal ducts into the cystic duct.

Sometimes the anatomical structure of the Calot’s triangle is not very clear because of the congestion, edema and fragility of the tissues around the cystic duct in acute suppurative or gangrenous cholecystitis, fibrous tissue scars are often formed in Calot’s triangle in atrophic cholecystitis. In such cases it is impossible to identify Calot’s triangle correctly. Maybe the more secure method is the retrograde cholecystectomy and to split the gallbladder, evacuate its contents, clear the free wall of the gallbladder out of the liver. The remnant mucosa of the gallbladder is then coagulated with electrocautery. The cystic duct orifice is closed with absorbable sutureıVicryl or Dexonı. It is better for use of a drain. It is more difficult to perform this procedure by LC or MC. MORE…

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