Wednesday, April 30, 2008

Laparoscopic Biliary Injuries (Part Two), prevention and presentation.

Prevention of biliary injuries

  • Experience should be graded and difficult procedures should not be attempted until experience has been gained.

  • Laparoscopic cholecystectomy is more difficult in the presence of acute inflammation, especially when the operation is delayed for several days and when leukocytosis is prominent.

  • Biliary injury is more likely under these circumstances.

  1. A previous attack of acute cholecystitis is also a significant contributing factor to operative difficulty.

  2. It is also more difficult in the presence of chronic inflammation with a thick-walled gallbladder and

  3. when the patients are
    • males,

    • elderly, or

    • when there have been repeated attacks of pain.

  • These factors are additive.

Avoidance of misidentification of ducts

  • Misidentification is due to failure to identify the cystic structures correctly

  • The cystic duct and artery are the only structures which require division during a cholecystectomy, and the objective of dissection is to identify these structures.

During open cholecystectomy this could be achieved by a tentative identification of the cystic structures by dissection in the triangle of Calot, followed by dissection of the gallbladder off the liver bed.

  • After complete detachment of the gallbladder, conclusive identification of the cystic structures, as the only two structures entering the gallbladder, could be made.

In 1995, Steven M. Strasberg et al introduced a technique for conclusive identification of the cystic structures at laparoscopic cholecystectomy based on a “critical view of safety”.

  • In this technique the triangle of Calot is cleared of all fat and fibrous tissue.

  • At this point only two structures are connected to the lower end of the gallbladder, and the lowest part of the gallbladder attachment to the liver bed has been exposed.

  • The latter is an important step, which is equivalent to taking the gallbladder off the liver bed in the open technique.

  • It is not necessary to see the common duct.

  • Once the critical view is attained cystic structures may be occluded, as they have been positively identified.

  • Failure to achieve the critical view is an absolute indication for conversion or possibly cholangiography to define ductal anatomy.

Some useful technical suggestions to aid clearing the triangle of Calot are

  • to dissect the triangle of Calot from both its dorsal and ventral aspects,

    • using a combination of pulling techniques,

    • gentle spreading with forceps,

    • and blunt dissection with a non activated spatula cautery tip or anchored pledgets

  • The pouch of Hartman should be pulled laterally and inferiorly to open the anterior left side of Calot’s triangle and create an angle between the cystic duct and common bile duct ( fig. 1)

  • The plane of dissection should always be maintained on the gallbladder or cystic duct.

  • To do so, the gallbladder should be followed down to the presumed point of the infundibulum–cystic duct junction and dissection started there.

Anatomical identification by routine operative cholangiography (RIOC) is an alternative approach to dissection.

  • There is now very strong evidence that RIOC can reduce biliary injury.

  • A population study in Australia found that RIOC reduced the incidence of injury.

  • This important study adjusted for confounding variables such as age, gender, hospital type, and severity of disease.

  • Its conclusions have been supported by other more recent studies.

  • Other studies suggest that the severity but not the incidence of biliary injury is reduced by RIOC.

  • Operative cholangiography is best at detecting a misidentification of the common bile duct as the cystic duct, and will prevent excisional injuries of bile ducts, provided that the cholangiogram is interpreted properly.

  • However, operative cholangiograms have been misinterpreted frequently in the presence of injury.

  • The most common misinterpretation is the failure to recognize that the bile duct rather than the cystic duct has been incised and cannulated when only the lower part of the biliary tree is seen.

  • Also an incisional injury of the common bile duct made to perform RIOC may not itself be innocuous.

  • It will at the least require conversion and repair over a T-tube and at worst require biliary reconstruction.

  • Furthermore, RIOC is very poor at detecting aberrant right ducts which unite with the cystic duct before joining the common duct.

  • The aberrant duct appears to be the cystic duct visually and on X-ray since other right-sided ducts fill ( fig. 2)

Some authorities believe that meticulous dissection of the triangle of Calot, as was done during the open era, is the correct means of anatomical identification.

  • The author’s view is that identification of the anatomy by the “critical view” technique is the method of choice for identification of biliary anatomy during laparoscopic cholecystectomy – but that if this method is not used, RIOC should be performed.

  • It is also one view that the infundibular technique should not be used without cholangiography and that ductal identification by dissection to the cystic duct/common hepatic duct union ought not to be used as a routine technique of ductal identification during laparoscopic cholecystectomy because of the danger of injury to the common bile duct, especially when there is a parallel union of the cystic duct with the common hepatic duct.

  • These issues are not resolved since even today the infundibular technique is an accepted form of surgical practice

  • However, there are two points on which almost all authorities would agree;

    • a method of conclusive identification should be used in all cholecystectomies and all methods are capable of failure under certain conditions.

The admonition that cystic structures be conclusively identified before transection means that an approved method of identification should be used and not that surgeons are capable of always identifying the structures correctly.

Avoidance of technical errors

  • Clips should be placed so that the tips can be seen projecting beyond the duct, free of extraneous material.

  • Clips should not be manipulated in the subsequent dissection.

  • The new type “locking clip” may provide more secure closure.

  • Clips should not be used when the cystic duct is thick.

  • Instead, two preformed ligature loops should be applied and tightened to occlude the cystic duct.

  • When the duct is very large a stapler may be used.

    • Applying extra clips is not the answer and may lead to tenting injury.

    • Tenting injury is also avoided by not pulling up on the gallbladder forcefully when applying clips and, most importantly, by direct observation that a piece of cystic duct remains below the clip applied closest to the common bile duct end of the cystic duct.

Avoidance of ductal injury in the liver bed depends upon

  • staying in the correct plane of dissection.

  • Use of the spatula dissector combined with irrigation to keep the field clear of blood is often helpful.

  • The cautery scissors are also useful, but there is no substitute for meticulous technique and experience in this dissection.

Cautery should not be used, or used only with great care, in the triangle of Calot.

  • Great care means low cautery settings, coagulation of small pieces of tissue at one time, and that tissue must be lifted off and be free of any adjacent tissue.

  • Low cautery settings are mandatory, as higher settings may lead to arcing to ducts.

  • Cautery should never be used to divide the cystic duct since this may lead to thermal necrosis of the cystic duct stump or adjacent bile duct.

Bleeding should never be controlled by blind application of clamps, clips, or cautery.

  • Brisk bleeding is an indication for conversion.

  • Lesser degrees of hemorrhage may appear more serious than they really are, because of the magnification of laparoscopy.

  • The operating surgeon must use judgment in such cases as the bleeding often stops spontaneously or with direct pressure.

Presentation and investigation

  • About 10% of type A injuries are identified intraoperatively; most of the rest are diagnosed in the first postoperative week.

  • Type B injuries are infrequently diagnosed intraoperatively; often they are silent or become symptomatic with right-sided abdominal pain or jaundice months or years after he cholecystectomy.

  • Type C and D injuries, which produce bilomas like type A injuries, tend to be diagnosed in the early postoperative period.

  • The type of injury most likely to be identified during the procedures the type E;

    • 25 to 40% of type E injuries are diagnosed intraoperatively according to most literature reports.

    • Most of the remaining type E injuries are identified in the first 30 days after surgery with the remaining presenting months to years after the laparoscopic cholecystectomy.

    • The preceding comments refer to the first presentation of injury.

    • In large series, 30 to 40% of repairs are performed on patients who have had a prior repair at the institution where the injury occurred.

Intraoperative identification of injury may occur by recognition of bile in the field, indicating a cut bile duct, by cholangiography, or rarely by direct observation of a divided duct.

At other times the actual diagnosis of biliary injury is made after conversion for bleeding or inability to proceed in a difficult dissection.

Postoperative presentations are influenced by the type of injury and whether a drain has been left. Pathological processes leading to symptoms are:

  • biloma,

  • fistula,

  • or bile ascites;

  • partial or complete biliary obstructions;

  • and superinfection.

These may occur in various combinations.

The commonest presentations are

  1. pain with sepsis with or without jaundice,

  2. and jaundice without other symptoms.

  3. Biliary fistula is also a common presentation.

  4. Some patients present only with distension and malaise.

There have been many papers written on the subject of investigation of symptoms developing after laparoscopic cholecystectomy, but there are no comparative trials of different algorithms.

Pain and sepsis

  • This presentation usually occurs in injuries leading to bilomas, that is types A, C, and D.

  • Most patients with type A injury present with the pain/sepsis symptom complex; jaundice is very uncommon but hyperbilirubinemia of (2 to 3 mg/dL) is often found, as is elevation of alkaline phosphatase level.

  • Few of the more serious type E injuries present only with pain/sepsis.

The purpose of investigation in the pain/sepsis group is to determine whether there is a biloma or bile ascites, whether there is continuing bile leakage, and the site of the leakage from the biliary tree.

Computed tomography (CT) scan is performed first to localize fluid collections which may then be aspirated to determine if they are bilious.

In most cases a drain is placed in the biloma and an endoscopic retrograde cholangiopancreatography (ERCP) follows.

Magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC)

  • has the potential to replace these investigations with a single one,

  • but MRC does not see collapsed ducts well,

  • and is more likely to be useful when there is obstruction of the biliary tree than perforation with free drainage of bile into the peritoneal cavity.

Since most patients presenting with pain/sepsis have type A or D injuries, definitive treatment is possible at the time of ERCP.

  • When bile ascites is found on CT, stable patients may be treated in the same manner with percutaneous drainage and ERCP,

  • but laparotomy, lavage, and drainage may be advisable for unstable patients with generalized bile ascites.

  • Another more circuitous approach when a collection is found is to perform a hepatobiliary iminodiacetic acid (HIDA) scan if bile is aspirated and proceed to drain placement and ERCP only if continuing leakage is demonstrated. The latter may be suitable for the minimally symptomatic patient.

Some patients presenting with pain and sepsis have more serious injuries.

  • In these patients the ERCP will demonstrate occlusion of the bile duct or free communication with the peritoneal cavity.

  • The next step to complete diagnosis of the extent of injury is by percutaneous transhepatic cholangiography (PTC),

    • but the period immediately after drainage of bile collections is often a poor time to do so in this group of non jaundiced patients whose bile ducts are not dilated.

  • Injection of drains at this time will frequently show a cloud of contrast and, as the bile ducts are not dilated, PTC as a primary step is difficult.

  • One often wait for 2 to 3 weeks until the biloma is resolved and a tract forms around the drain.

  • At this time injection of the drain will result in filling of the biliary tree, that is a fistulagram is possible.

  • This permits diagnosis of the extent of the injury.

  • Furthermore, once intrahepatic ducts can be filled with contrast, insertion of percutaneous tubes into intrahepatic bile ducts under fluoroscopy is possible.

It is critical that all intrahepatic ducts be accounted for.

  • In type E1 to 3 injuries cannulation of any intrahepatic duct will result in filling of all intrahepatic ducts as they are in communication.

  • In higher injuries this is not the case and more than one intrahepatic duct will require cannulation to identify all the intrahepatic ducts.

  • It is not difficult to fail to appreciate that ducts from a particular volume of liver are not filling,

    • but this has obvious, serious consequences if not recognized before repair is undertaken.

To avoid this problem the recommendation is to reconciliation between PTC studies and a CT scan of the liver.

  • Livers are variably shaped and this type of reconciliation, which correlates the shape of the PTC volumes with the whole liver volume, provides confidence that all ducts are accounted for.

  • The commonest problem is failure to appreciate that right posterior sectional ducts are absent on PTC in patients whose right liver descends inferiorly more than usual.


  • The presence of jaundice strongly suggests that the patient has sustained a type E injury.

  • Type E injuries present with jaundice in about 70% of cases, the other 30% presenting with pain/sepsis only as described above.

  • Occlusions usually present with jaundice as the sole symptom, but transactions are often accompanied by pain and sepsis due to accumulation of bile in the peritoneal cavity.

ERCP is the first-line investigation today, although it may be supplanted by MRCP in the future.

MRCP is especially effective when the bile ducts are occluded.

  • The bile-filled ducts show up well under these circumstances.

  • On ERCP the duct may be found to be occluded often clips are seen at the point at which the dye column stops.

  • Or it may be found to be transected, with loss of continuity to the upper biliary tract.

  • If stenotic rather than occluded ducts are found, the entire extent of injury may be diagnosed by ERCP.

  • When the upper ducts cannot be seen by ERCP, PTC is required.

  • When the upper ducts are occluded and dilated, PTC is straightforward.

  • When they are not the approach of delayed PTC as described under pain/sepsis is recommended.

  • PTC also provides external drainage of bile.

The presence of bile collections may require percutaneous drainage as well.

Bile fistula

  • About one-third of patients with type A injury present with bile fistula, but any injury in which there is a bile leak may do so.

  • Since bile has egress, local collections or obstruction to bile flow are unlikely and sepsis and jaundice are usually absent.

The first-line investigation is a fistulagram. Subsequent management depends upon anatomical findings.

Vague symptoms

  • A few patients present only with vague symptoms such as distension, malaise, anorexia, complaints of discomfort, or may require more than the usual amount of analgesia.

  • These presentations are usually due to bile ascites, but hepatic bile is isotonic and has a low bile salt concentration compared to gallbladder bile and so may cause little irritation until infection occurs.

  • The mild complaints are easy to overlook, but may be the only manifestations of a serious biliary injury and diagnostic delay is a key factor in stimulating litigation.

The suggested line of investigation is the same as for pain/ sepsis.

Hemobilia is a rare presentation of biliary injury and is due to pseudoaneurysm formation at the site of an associated arterial injury with subsequent erosion into the biliary tree.

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