Die intraoperative laparoskopische Cholangiografie - Wann ist sie sinnvoll?

Clinical application of the hanover classification for iatrogenic bile duct lesions

Background. There is only limited evidence available to justify generalized clinical classification and treatment recommendations for iatrogenic bile duct lesions. Methods. Data of 93 patients with iatrogenic bile duct lesions was evaluated retrospectively to analyse the variety of encountered lesions with the Hanover classification and its impact on surgical treatment and outcomes. Results. Bile duct lesions combined with vascular lesions were observed in 20 patients (21.5%). 18 of these patients were treated with additional partial hepatectomy while the majority were treated by hepaticojejunostomy alone (n = 54). Concomitant injury to the right hepatic artery resulted in additional right anatomical hemihepatectomy in 10 of 18 cases. 8 of 12 cases with type A lesions were treated with drainage alone or direct suture of the bile leak while 2 patients with a C2 lesion required a Whipple's procedure. Observed congruence between originally proposed lesion-type-specific treatment and actually performed treatment was 66–100% dependent on the category of lesion type. Hospital mortality was 3.2% (n = 3). Conclusions. The Hannover classification may be helpful to standardize the systematic description of iatrogenic bile duct lesions in order to establish evidence-based and lesion-type-specific treatment recommendations.

Laparoscopic common bile duct exploration

OBJECTIVE

To describe the technique of laparoscopic common bile duct exploration (LCBDE) with high clearance rates, low morbidity, and mortality rates.

SUMMARY BACKGROUND DATA

LCBDE is well accepted by patients because treatment is obtained during the same anesthesia. If one stage therapy for gallstones and common bile duct stones provides success rates equivalent to those of the sequential approach, with lower costs, this should be considered the standard of care.

METHODS

From September 1991 to March 2007, 5201 laparoscopic cholecystectomies were performed at São José Avaí Hospital. LCBDE was carried out in 481 patients (9.25%).

RESULTS

Of 481 LCBDE, 225 (46.78%) were managed using a transcystic approach and 183 (38.05%) with choledochotomy (114 with transcystic choledochotomy and 69 with longitudinal opening of the common bile duct). Successful laparoscopic stone clearance was achieved in 468 (97.3%). An elective postsurgical endoscopic sphincterotomy were done on the 13 (2.70%) patients not cleared laparoscopically. Seven patients had unexpected retained stones.

CONCLUSIONS

LCBDE during laparoscopic cholecystectomy solves 2 problems during the same anesthesia with high success rates and may be employed successfully.

Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems

BACKGROUND

Different injury patterns of iatrogenic bile duct lesions after cholecystectomy have prompted the proposal of several different clinical classification systems. The aim of this study was to validate these systems comparatively.

METHODS

Results after surgical intervention for iatrogenic bile duct lesions in 74 consecutive patients at a tertiary referral centre were reviewed retrospectively. A new classification (Hannover classification) for iatrogenic bile duct lesions is proposed and compared with four other systems using the present clinical data.

RESULTS

Additional vascular lesions were found in 19 per cent. The hospital mortality rate was 3 per cent and the overall hospital complication rate after repair was 26 per cent. Sixteen of 74 patients required early surgical reintervention. The Hannover classification demonstrated a highly significant association between the discrimination of classifiable injury patterns and the different surgical treatments chosen (P < 0.005). The Strasberg and Neuhaus classifications do not consider vascular involvement, whereas the Stewart-Way, Siewert and Neuhaus systems do not discriminate between lesions at or above the bifurcation of the hepatic duct.

CONCLUSION

Additional vascular involvement and location of the lesion at or above the bifurcation of the hepatic duct have a major impact on the extent of surgical intervention required and should be reflected in any classification of bile duct injuries.