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Risk of biliary tract injury during laparoscopic surgery
Dr Fadhl Ali Almohtady
Open cholecystectomy was the standard practıce for treartment of symptomatıc gallbladder dısease untıl later 1980
At present more than 90% of cholecystectomıes are performed by laparoscopy whıch become one of the commonest surgıcal procedure ın the world.
Unfortunately the wıdespread used of laparoscopy has lead to a concurrence rıse ın the ıncıdence of major bıle duct ınjury(BDI)
Deziel D J et al Chicago Illinois - Am J of Surg 165 January 1993
Most lethal complications
OC :has been associated wıth 0.2%-0.4% risk of BDI.
ON THE OTHER HAND (LC): has been associated with 2.5 fold to 4 folds increase in the incidence of post operative BDI.
in 1990 high rate of BDI ıs due to in part to learnıng curve effect .
A surgeon had ı.7% chance of BDI ın the first case a 0.17%chance of BDI after the 50th case.
However,most surgeon passed through the learning curve (steady state)
(Maraca R.J et al : Arch Surge 2003, 137:889-894)
(Gouma DJ and Obertrop H : BJS 2002,89,385-386)
Lacey Clinic, Burlington, MA.1994
Blumgart LH. Surg Clin N Am. 1994.74.4
.loss of depth perceptıon
Lack of manual palpatıon
Surgeon dependant to equıpment
Blınd manıpulatıon the ınstruments
--Mistaking the common bile duct for the cystic duct
Lahey Clinic, Burlington, MA.1994
Lacey Clinic, Burlington, MA 1994
There are many classıfıcatıon systems,
Bismuth ,McMahon, Strasberg, Amesterdam academic medical center;s classificatıon, Stewart and so and so……..
PURPOSE to know the severıty of the ınjury.
Communıcatıon purposes between doctors and centers
Treatment purposes –modalıty of treatment
1Low CHD stricture, with a length of the common hepatic
duct stump of >2 cm
2Proximal CHD stricture-hepatic duct stump <2 cm
3 Hilar stricture, no residual CHD, but the hepatic ductal
confluence is preserved
4Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct
5Involvement of aberrant right sectorial hepatic duct alone orwith concomitant stricture of the CHD.
Bismuth classification of bile duct strictures
Lacey Clinic, Burlington, MA.1994
TYPE OF INJURY
1-Laceratıon > 25% of bıle duct dıameter.
2-Trasectıon of CHDor CBD.
3-Development of post-operatıve stıcture.
1-Laceratıon of<25% of BD dıameter.
2-Laceratıon of cystıc-CBD junctıon(buttonhole tear)
4 TYPES OF BDI CAN BE IDENTIFIED (MCMOHAN)
TYPE A:cystıc duct leak or leakage from a berrant or perıpheral hepatıc radıcles.
TYPE B:major bıle duct ınjury wıth or wıthout concomıtant bılıary strıcture.
TYPE C:bıle duct stıcture wıthout bılıary leakage.
TYPE D:complete transectıon of BD wıth or wıthout excısıon a part of the duct.
Ⅰ CBD mistaken for cystic duct, but recognized
Cholangiogram incision in cystic duct extend
Ⅱ Bleeding, poor visibility Multiple clips placed on CBD/CHD
ⅢCBDmistaken for cystic duct, not recognized
CBD, CHD, or right or left hepatic ducts transected and/or
Ⅳ Right hepatic duct (or right sectorial duct) mistaken for
Right hepatic artery mistaken for cystic artery
Right hepatic duct (or right sectorial duct) and right
hepatic artery transected
About 25% of BDI discovered ıntra-operatıvely.
About 25% of BDI dıscovered after 24-48 hs post-operatıvely.
And about 50% of BDI present weeks ,months or years post operatıvely
Warko karnadihardja- 2004
Quicker the repair, the better the outcome!!!
History of unexplained fevers, pain, abnormal liver function test results, or pruritus
Should prompt an investigation
adequate multidisciplinary approach in a tertiary care center are the cornerstones for good outtcome.