Bile duct injury during laparoscopic cholecystectomy: results of a national survey

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment of symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC is used to show cystic ducts that are not seen by MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with nonvisualized cystic ducts by MRC. To our knowledge, this is the first study of visualization of cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is the preferred treatment for symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC was used to show cystic ducts that are not seen on MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with cystic ducts not seen on MRC. To our knowledge, this is the first study of visualization of a cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.

Rate of elective cholecystectomy and the incidence of severe gallstone disease

BACKGROUND

The use of elective cholecystectomy has increased dramatically following the widespread adoption of laparoscopic cholecystectomy. We sought to determine whether this increase has resulted in a reduction in the incidence of severe complications of gallstone disease.

METHODS

We examined longitudinal trends in the population-based rates of severe gallstone disease from 1988 to 2000, using a quasi-experimental longitudinal design to assess the effects of the large increase in elective cholecystectomy rates after 1991 among people aged 18 years and older residing in Ontario. We also measured the rate of hospital admission because of acute diverticulitis, to control for secular trends in the use of hospital care for acute abdominal diseases.

RESULTS

The adjusted annual rate of elective cholecystectomy per 100,000 population increased from 201.3 (95% confidence interval [CI] 197.0-205.8) in 1988-1990 to 260.8 (95% CI 257.1- 264.5) in 1992-2000 (rate ratio [RR] 1.35, 95% CI 1.32- 1.38, p 0.001). An anomalously high number of elective cholecystectomies were performed in 1991. Overall, the annual rate of severe gallstone diseases (acute cholecystitis, acute biliary pancreatitis and acute cholangitis) declined by 10% (RR 0.90, 95% CI 0.88- 0.91) for 1992-2000 as compared with 1988-1991. This decline was entirely due to an 18% reduction in the rate of acute cholecystitis (RR 0.82, 95% CI 0.80-0.84).

INTERPRETATION

The increase in the rate of elective cholecystectomy that occurred following the introduction of laparoscopic cholecystectomy in 1991 was associated with an overall reduction in the incidence of severe gallstone disease that was entirely attributable to a reduction in the incidence of acute cholecystitis.

Reducing errors in the operating room: surgical proficiency and quality assurance of execution

Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors--both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment.

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

BACKGROUND

Over 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.

METHODS

gall 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.

RESULTS

Between 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.

CONCLUSION

The 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.

Ten-year trend in the national volume of bile duct injuries requiring operative repair

BACKGROUND

The objectives of this study were to determine the national proportions and mortality rate for bile duct injuries resulting from laparoscopic cholecystectomy (LC) that required operative reconstruction for repair over a 10-year period and to investigate the major factors associated with the mortality rate in this group of patients.

METHODS

Using the Nationwide Inpatient Sample (NIS) of >7 million patient records per year, we extracted and analyzed data for LC during the years 1990-2000. Procedures that involved biliary reconstructions performed as part of another primary procedure were excluded. Using the Statistical Package for the Social Sciences (SPSS), we used procedure-specific codes that enabled us to calculate national estimates for LC for the time period under review. We then calculated biliary reconstruction procedures that occurred after LC for this cohort of patients. Finally, we analyzed in-hospital mortality, as well as the patient, institutional, and outcome characteristics associated with biliary reconstructions.

RESULTS

The percentage of cholecystectomies performed laparoscopically has increased over the years for which data are available (from 52% in 1991 to 75% in 2000). Despite this increase, the mortality rate for this group of patients has remained consistently low over the study period (mean, 0.45%; range 0.33-0.58%). Within this group of patients, the average rate of bile duct injuries requiring operative repair was 0.15% for the years under study. The reconstruction rates ranged from 0.25% in 1992 to 0.09% in 1999. For 2000, the most recent year for which data are available, biliary reconstruction was performed in 0.10% of all patients who underwent LC. The average mortality rate for patients undergoing biliary reconstruction for the years 1991 to 2000 was 4.5%. After multivariate analysis, age, African American ethnicity, type of admission, source of admission, and hospital location, and teaching status were all found to correlate significantly with death after-biliary reconstruction.

CONCLUSIONS

These data show an increase in the percentage of cholecystectomies performed laparoscopically over the years under study and an associated low mortality rate. In contrast, although the number of bile duct injuries appears to be decreasing, these procedures continue to be associated with a significant mortality rate.

Does routine intraoperative cholangiography prevent bile duct transection?

BACKGROUND

The role of routine intraoperative cholangiography is controversial. The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries, and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature.

METHODS

Prospectively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were reviewed.

RESULTS

The mean age of the study sample (65.6% male, 34.4% female) was 54 years, and 16.9% of the patients had clinical acute cholecystitis. The conversion rate to open cholecystectomy was 4.3%. Intraoperative cholangiography was attempted for 90.7% of the patients with a 95.9% success rate. Five patients (0.16%) had common bile duct injuries. Four injuries had occurred in the first 5 years. One injury (0.06%) had occurred after 1995. This injury was identified intraoperatively and repaired laparoscopically. Routine intraoperative cholangiography prevented one definite common bile duct transection.

CONCLUSIONS

In this series using routine intraoperative cholangiography, there was a low rate and severity of common bile duct injuries, with a high intraoperative recognition rate. There was no bile duct transection or major injury requiring common bile duct reconstruction. Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy, injury was not completely prevented.

Le risque de plaies biliaires au cours de la cholécystectomie par laparoscopie

The incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. 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. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon 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; there is no substitute for experience and caution in biliary 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.

Laparoscopic iatrogeny of the hepatic hilum as an indication for liver transplantation

The introduction of biliary laparoscopic surgery led to an increase in the incidence of liver hilum injuries. These types of lesions are very serious, because they can lead to secondary biliary cirrhosis or fulminant hepatic failure and the need for liver transplantation (LT). We present three cases of liver hilum injuries, which were treated with LT; one case was due to severe and persistent cholangitis, and two cases were due to fulminant hepatic failure. The world literature is also reviewed, and published cases of iatrogenic lesions of the liver hilum caused by laparoscopic surgery and requiring LT are presented. These iatrogenic lesions of the hepatic hilum are complex and technically demanding, due to their high morbidity and mortality and even the need for LT. In conclusion, these lesions must be always managed in centers with experience in hepatobiliary surgery.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

Current management of postoperative complications and benign biliary strictures

Postoperative complications after surgery of the biliary tract are usually amenable to endoscopic treatment. Such complications are most frequent after laparoscopic cholecystectomy. Bile leaks and bile duct strictures are the two main biliary injuries. Bile leaks are usually detected during the early postoperative period and can be treated by endoscopic drainage of the biliary tree (endoscopic sphincterotomy with or without nasobiliary drain). Postoperative biliary strictures are usually identified months or years after surgery. Endoscopic placement of an increasing number of plastic stents can achieve morphologic disappearance of the stricture and persistent dilation on long-term follow-up in most cases.

Psychomotor skills assessment in practicing surgeons experienced in performing advanced laparoscopic procedures

BACKGROUND

Minimally invasive surgery (MIS) has introduced a new and unique set of psychomotor skills for a surgeon to acquire and master. Although assessment technologies have been proposed, precise and objective psychomotor skills assessment of surgeons performing laparoscopic procedures has not been detailed.

STUDY DESIGN

Two hundred ten surgeons attending the 2001 annual meeting of the American College of Surgeons in New Orleans who reported having completed more than 50 laparoscopic procedures participated. Subjects were required to complete one box-trainer laparoscopic cutting task and a similar virtual reality task. These tasks were specifically designed to test only psychomotor and not cognitive skills. Both tasks were completed twice. Performance of tasks was assessed and analyzed. Demographic and laparoscopic experience data were also collected.

RESULTS

Complete data were available on 195 surgeons. In this group, surgeons performed the box-trainer task better with their dominant hand (p < 0.0001) and there was a strong and statistically significant correlation between trials (r = 0.47 - 0.64, p < 0.0001). After transforming raw data to z-scores (mean = 0 and SD = 1) it was shown that between 2% and 12% of surgeons performed more than two standard deviations from the mean. Some surgeons' performance was 20 standard deviations from the mean. Minimally Invasive Surgical Trainer Virtual Reality metrics demonstrated high measurement consistency as assessed by coefficient alpha (alpha = 0.849).

CONCLUSIONS

Objective assessment of laparoscopic psychomotor skills is now possible. Surgeons who had performed more than 50 laparoscopic procedures showed considerable variability in their performance on a simple laparoscopic and virtual reality task. Approximately 10% of surgeons tested performed the task significantly worse than the group's average performance. Studies such as this may form the methodology for establishing criteria levels and performance objectives in objective assessment of the technical skills component of determining surgical competence.

Patient safety in surgery: error detection and prevention

Error in medicine is becoming a well recognized phenomenon. The U.S. Institute of Medicine's publication in 1999 included estimations that medical error is the eighth leading cause of death in the United States and results in up to 100,000 deaths annually. Retrospective studies and a few prospective studies are shedding more light on this challenging problem. Strategies to reduce error and increase patient safety have not been widely developed or embraced by surgeons for a variety of reasons. We provide a review on patient safety aimed at surgeons that includes definitions, incidence of errors including those in the surgical literature, causes of error, methods of error detection, and strategies to minimize errors and maximize patient safety.

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.

Nationwide decline in annual numbers of abdomino-perineal resections: effect of a successful national trial?

OBJECTIVE

Large national trials may influence surgical practice. In this study the relation between the successful national randomized trial on the management of rectal cancer (the Dutch TME trial) and national ratio of abdomino-perineal resection to low anterior resection and anastomosis was analysed.

PATIENTS AND METHODS

In the study period, 1994-99, 15978 patients underwent either abdomino-perineal resection (n = 2575) or low anterior resection and anastomosis (n = 13403). The Dutch TME trial started in 1996 and a total of 1530 patients were included by 83 hospitals and 82.1% of these patients were treated from 1997 to 1999. Teaching sessions, tutor assisted surgery and quality control formed an integral and important part of the TME trial.

RESULTS

Ratio of abdomino-perineal resection vs. low anterior resection was compared between period I (1994-96) and period II (1997-99). The ratio decreased from 0.19 to 0.13 between period I and II (95% CI, -0.08 to -0.04, P < 0.001). In hospital mortality rate did not change between period I and II (3.5 vs. 3.7, 95% CI, -0.08 to 0.03, P=0.385).

CONCLUSION

Significant changes in surgical attitude may accompany successful national randomized trials in which investigated surgical procedures are specified, taught, and controlled. The APR ratio declined by 32% in the Netherlands during and following the Dutch TME trial, without a rise in hospital mortality rate for rectal resections.