Lasers in Surgery and Medicine 12:92-97 (1992)
Complications of Laparoscopic Cholecystectomy: A Prospective Review of an Initial 100 Consecutive Cases John N. Graber, MD, FACS, Leonard s. Schultz, MD, FACS, Joseph J. Pietrafitta, MD, FACS, and David F. Hickok, MD, FACS Abbott Northwestern Hospital, Minneapoiis, Minnesota 55404 (J.N.G., L.S.S., J.J.P., D.F.H.):Department of Surgery, University of Minnesota, Minneapoiis, Minnesota 55455 (J.N.G., L.S.S., D.F.H.)
In order to identify problems in concept or technique with laparoscopic cholecystectomy, a prospective analysis of the initial consecutive 100 procedures was accomplished. Ongoing review of the results led to modifications in order to improve operative outcome. Minor complications such as nausea for more than 12 h (2046)and right shoulder pain (29%)were self-limiting.There were no deaths, two bile duct injuries, two abscesses, two retained common duct stones, and one case requiring transfusion, totaling a 745,major complication rate. In the subsequent 200 laparoscopic cholecystectomies,there was a 1.5%rate of major complications. Specific measures and modifications in technique that account for this improvement are detailed. Complications of laparoscopic cholecystectomy are more frequent in initial cases but can be minimized by observing specific intraoperative principles. Key words: bile duct injury, postoperative abscess, retained stones
INTRODUCTION
The acceptance of laparoscopic cholecystectomy by surgeons has been uncharacteristically rapid. The driving force behind this change was the tremendous public interest in less invasive medical techniques [l1. Laparoscopic cholecystectomy has been reported as offering less hospitalization, less pain, less incision, and less recovery time while still delivering the same quality outcome as incisional cholecystectomy 12-41. Many anecdotal accounts of problems appear in the literature, but there has been no detailed report of complications [51. The purpose of this study is to delineate problems in technique and concept that could lower the quality of the operative outcome. Awareness of these matters could then allow for concentrated efforts to eliminate or minimize them. MATERIALS AND METHODS
One hundred conisecutive laparoscopic &olecystectomies were completed or attempted under 0 1992 Wiley-Liss, Inc.
a n Institutional Review Board Protocol in a private hospital by two surgeons. The demographics and preoperative symptoms of the patients are listed in Tables 1 and 2. All patients had extensive personal preoperative review of the technique and potential complications of the operation with the surgeon. The last 45 patients in the series watched a preoperative video designed to review the nature of the operation and better familiarize the patients with the procedure. The patients were admitted to the hospital the morning of the operation. Preoperative prophylactic antibiotics were given to 85 patients. General anesthesia was induced, and the patients were prepped and draped in standard fashion as for laparotomy. A pneumoperitoneum was obtained by instilling carbon dioxide gas through a
Accepted for publication October 7, 1991. Address reprint requests to Dr. John N. Graber, 2545 Chicago Ave. S. #600, Minneapolis, MN 55404.
Complications of Laparamopic Cholecystectomy TABLE 1. Demographics, N = 100 TABLE 3. Preoperative vs. Operative
93
Diagnoses, N = 100
Sex Male Female
N N
Age Range Average
18-80 yr 47 yr
=
=
39 61
TABLE 2. Preoperative SvmDtoms. N = 100
Diagnosis Chronic cholecystitis Cholelithiasis Acute cholecystitis Cholesterolosis Carcinoma of the gallbladder
Preoperative 100 100 0
Operative 99 86 8 17 1
were identified in these categories). In the setting of positive intraoperative cholangiograms (two patients), the cholecystectomy was completed; if the stones were >4 mm or symptomatic, a postoperative ERCP was performed (both cases). The patients were prospectively observed for complications during the operation, in the immediate postoperative period, and throughout the Verres needle placed through a periumbilical follow-up period, which extended to 26 months. puncture. A 10-mm trocar sleeve was then in- Any complications were specifically evaluated to serted into the abdominal cavity, and a 45" side- determine their precise cause. As much as possiviewing laparoscope was inserted. A cursory ex- ble, appropriate changes in the patient care and amination of the abdominal contents was technique were made to avoid further incidences accomplished, after which a cholecystcholangio- of the same complication. gram was performed by injecting 35 ml of 50% contrast into the gallbladder through a 13-gauge RESULTS needle. A second radiograph was taken after inThe preoperative diagnosis is compared with jecting another 35 ml of contrast. Residual dye was removed. Gallbladder adhesions were then the operative diagnosis in Table 3. It is not entaken down using blunt and sharp technique and tirely clear why only 86 of the 100 cases were bipolar cautery. The cystic duct was dissected, found to have stones by the pathologist; in all clipped, and divided using the contact neodym- cases, the surgeon reported identifying stones and ium:YAG (Nd:YAG) laser technique. The laser in at least six of these 14 cases, the stone(s) were was also used to remove the gallbladder from the lost and left in the intraperitoneal space. We canliver bed in a retrograde fashion. Bleeding in the not account for the absence of the stones seen by liver bed was controlled with bipolar and unipolar the pathologist in the other eight cases. Microcautery. The gallbladder was removed intact or scopic examination showed all 100 gallbladders to morselated through an 11-mm trocar sleeve. Any be pathological. Six of the 100 cases were converted to open residual intraperitoneal stones or debris were meticulously removed with cupped forceps or flushed laparotomy. In four of these six cases, it was dewith saline and aspirated; 1 g of cefazoline was cided to abandon the laparoscopic approach beadded to the irrigant. None of the fascia1 punc- cause the anatomy could not adequately be distures was extended in order to remove the gall- cerned laparoscopically. Associated pathology in bladder or stones; therefore, no sutures were these four cases was acute cholecystitis in three placed in the fascia at closure. A single intracu- cases and advanced cirrhosis in the other patient. ticular stitch was used to close the skin at each The other two cases were opened to control bleedpuncture site. Patients were discharged home ing. One was to ligate a rapidly bleeding cystic when they could ambulate without difficulty and artery in a patient found to have unsuspected carcinoma of the gallbladder. This patient required a could tolerate a regular diet. Patients who presented with signs of possi- transfusion that was considered a major complible common bile duct stones preoperatively were cation. The other was to control on going liver bed not treated differently unless they were jaundiced oozing in association with severe cirrhosis. The incidence of minor complications obor had pancreatitis, in which case a preoperative ERCP would have been performed (no patients served is listed in Table 4. Major complications SvmDtoms RUQ abdominal pain in episodes Nausea Ultrasound shows stones Asvmutomatic trallstones
N 90 75 100 0
94
Graber et al. TABLE 5. Major Complications of LaDaroscoDic Cholecvstectomv
TABLE 4. Minor Complications of Laparoscopic Cholecystectomy, N = 100 Complications Nausea lasting > 12 h Right shoulder pain (due to diaphraghmatic irritation) Right costal margin pain Puncture site complications Infection requiring I & I) at 7 days PO Infection requiring antibiotics only Prolonged site pain Excessive scarring Hematoma (minor! Subcutaneous emphysema (lasting vi
-
, , ,v Retracted , Gall Bladder Cystic Duct
,I
~,~,,, ~
Duodenum Common Duct
D. Correct
Opeking to Hepatic Duct
Hepatic Duct
Fig. 1. Mechanism of misidentification of bile ducts. A. SagittaI view of normal gallbladder and ductal anatomy. B. Distorted view of cysticlcommon duct junction due to forceful anterior retraction on the gallbladder. C. Anatomy as viewed through a laparoscope, common bile duct is misidentified as a
tions specifically associated with laser or cautery use.
long cystic duct and incorrectly encircled. D. Beginning dissection on the gallbladder, identifying the actual cysticlcommon duct junction, and viewing from different angles with a side viewing laparoscope ensures correct identification of the cystic duct.
amount of experience one has with laparoscopic technique is a major factor. Not visualizing the cystic/common duct junction takes away a major Bile Duct injuries landmark in anatomical identification. Second, forceful anterior retraction on the Of interest is the fact that both bile duct injuries in this series were not recognized until the gallbladder, as is done laparoscopically in order to patient became jaundiced 4 or 5 days later. This view the cystic duct, distorts the normal angle of speaks to the nature of the injuries; that is, they the cystic/common duct junction by straightening are not the consequence of inadvertent mechani- it out. This can falsely make the cystic and comcal trauma but instead are the result of a misin- mon duct appear as one continuous cystic duct, and the dissection is carried past the junction terpretation of the anatomy. The primary problem is misidentification of without recognizing it. Anecdotally, this seems to the cystic/common duct junction (Fig. 1).There be the most common mechanism of misidentificaare several reasons for this. First, there is reluc- tion. In conjunction with a concern that further tance to clearly dissect the junction for fear of dissection is more risky and that a “long enough” bleeding or other injury. The extent of the dissec- segment of duct has been exposed, absolute idention down the cystic duct relates to the confidence tification of the cystic/common duct junction is that a surgeon has that it can be done safely. The abandoned and the wrong duct is transected.
Graber et al. Third, the field o f view generated by the 0" vices can remove it, lack of good retraction instruviewing laparoscope is limited in that it may al- ments, and a limited number of ports available for low only one perspective. As a consequence, the the insertion of retractors, camera, and vessel occommon hepatic duct, which extends from the cluding instruments. Bleeding is such a nuisance, it is better other side of the cysticlcommon duct junction into the liver may not be seen. Not visualizing the avoided than treated. Any potential vascular common hepatic duct can only confirm a mistaken structures should be coagulated before they are impression that the common duct is the cystic cut, and all bleeding should be controlled as soon as it is observed. If the camera lens is temporarily duct. We believe that it is necessary to adhere to coated with blood, the retractors should be used several principles in order to minimize the chance on the gallbladder to compress the gallbladder itof bile duct injury. First, when dissecting the cys- self against the site of bleeding and the lens tic duct, begin on the neck of the gallbladder and cleaned, followed by step-by-step exposure of the encircle it 360" around. There is a tendency to vessel. One should start with the laparoscope pobegin dissection at an obvious and convenient site sitioned far away from the site t o see what is godistal to the gallbladder, but there is a chance ing on "at a distance"; the retractors are moved to that a structure encircled here may be the com- prevent spurting. The laparoscope is advanced to mon duct regardless of initial impressions. Once improve the view. All pooled blood is irrigated the duct is encircled at the neck of the gallblad- and aspirated and the retractors carefully moved der, progressive distal dissection can be contin- so that the vessel can be seen. Most of the time the vessel can be coagulated or clipped successfully, ued. Second, use of a laparoscope which views at but if there is any doubt about causing injury to 45" or 30" t o the side may be helpful t o allow vi- other structures such as the common hepatic duct sualization around the backside of the duct. By (as in one of our cases), the surgeon would be best rotating the scope 180", a view around the other advised t o maintain compression and convert t o side of the duct can be obtained. Newer flexible laparotomy . Heparin (2,000 U) added t o 1 L of irrigant laparoscopes offer the same advantage by elimimay help avoid the tenacious clots that are diffinating the fixed perspective of the 0" scopes. Third, dissection t o the common duct junc- cult to aspirate. For control of liver bed bleeding, tion offers the most convincing evidence of correct unipolar cautery is dramatically better than bianatomical identification. This should be accom- polar. plished t o the extent that it is technically possible Abscess Formation and safe. Lastly, cholangiography should be considClearly, the major issue in preventing an abered in all cases. A cholecystcholangiogram, as scess is t o minimize any residual debris, bilious done in this series, can be done quickly, reliably fluid collections, or hematomas. Although sterile and offers a look at the anatomy before dissection gallstones left in the peritoneal cavity have been of the cystic duct is begun [61. A cystic duct cho- shown not to cause infection in animals [41, and langiogram is done through a small ductotomy many times stones escape the surgeon both inciand would identify any errors which can then be sionally and laparoscopically without consecorrected without serious injury. Despite these quence, any such residual debris enhances the observations, we experienced two more common chance of infection. Improved techniques for rebile duct injuries within the next 200 cases. Upon moving the gallbladder and gallstones from the review of these two cases, these principles were abdominal cavity will be developed, but meticulous attention t o the removal of all debris and not adhered t o rigidly. fluid will always be important. A Silastic drain Bleeding did not prevent one of the abscesses from forming Intraoperative bleeding is part of surgery. in our series. It is unclear that prophylactic antiControl of bleeding vessels depends on the opera- biotics or antibiotic irrigation will have any effect tor's ability t o identify and expose the source and on the rate of abscess formation. We recommend then occlude the vessel. Laparoscopic exposure of copious irrigation of the right upper quadrant visa rapidly bleeding vessel is compromised by blood ceral surfaces at the conclusion of the procedure. spurting onto the scope lens, pooling blood cover- All irrigant is removed, especially along the right ing the vessel faster than the limited suction de- lateral abdominal wall adjacent to the liver. 96
Complications of Laparoscopic Cholecystectomy 97 Retained Common Duct Stones ciples, their occurrence can be minimized. Along
At the time this series was accomplished, there was no well-described technique for laparoscopic removal of common duct stones. This and improvements in technique of cholangiography have already been described [61. The major issue is identification of these common duct stones intraoperatively so that a treatment plan can be applied. For patients who have postoperative biliary tract symptoms, an immediate liver function test should be obtained and, if abnormal, consideration of ERCP. CONCLUSION
Review of the complications seen in the first 100 cases led to changes in technique and procedure that in a dramatic improvement in the incidence Of subsequent complications. duct injuries are the most Severe problems Seen in this series and, with observation of specific prin-
with other changes in technique, improvements in instrumentation will further this effort. REFERENCES 1. Graber J. The future of surgery is “less invasiveness.” J Laparoendosc Surg 1990; 157. 2. Perissat J, Collet DR, Belliard R. Gallstones: Laparoscopic treatment, intracorporcal lithotripsy followed by cholecystostomy or cholecystectomy-a personal technique. EndosCOPY 1989 21:373-374. 3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3:131-133. 4. Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic cholecystectomy. A laboratory study. Presented a t the American Society for Laser Medicine and Surgery, Arlington, VA, April 1989 (abst). 5. Cole HM (ed): Questions and Answers: Laparoscopic cholecystectomy. JAMA 1991; 265:1585-1587. 6. Pietrafitta J, Schultz L, Graber J, Josephs L, Hickok D. Cholangiography during laparoscopic cholecystectomy: Cholecystcholangiography or cystic duct cholangiography. J Laparoendosc Surg 1991; 1:197-206.
Complications of Laparoscopic Cholecystectomy: A Prospective Review of an Initial 100 Consecutive Cases John N. Graber, MD, FACS, Leonard s. Schultz, MD, FACS, Joseph J. Pietrafitta, MD, FACS, and David F. Hickok, MD, FACS Abbott Northwestern Hospital, Minneapoiis, Minnesota 55404 (J.N.G., L.S.S., J.J.P., D.F.H.):Department of Surgery, University of Minnesota, Minneapoiis, Minnesota 55455 (J.N.G., L.S.S., D.F.H.)
In order to identify problems in concept or technique with laparoscopic cholecystectomy, a prospective analysis of the initial consecutive 100 procedures was accomplished. Ongoing review of the results led to modifications in order to improve operative outcome. Minor complications such as nausea for more than 12 h (2046)and right shoulder pain (29%)were self-limiting.There were no deaths, two bile duct injuries, two abscesses, two retained common duct stones, and one case requiring transfusion, totaling a 745,major complication rate. In the subsequent 200 laparoscopic cholecystectomies,there was a 1.5%rate of major complications. Specific measures and modifications in technique that account for this improvement are detailed. Complications of laparoscopic cholecystectomy are more frequent in initial cases but can be minimized by observing specific intraoperative principles. Key words: bile duct injury, postoperative abscess, retained stones
INTRODUCTION
The acceptance of laparoscopic cholecystectomy by surgeons has been uncharacteristically rapid. The driving force behind this change was the tremendous public interest in less invasive medical techniques [l1. Laparoscopic cholecystectomy has been reported as offering less hospitalization, less pain, less incision, and less recovery time while still delivering the same quality outcome as incisional cholecystectomy 12-41. Many anecdotal accounts of problems appear in the literature, but there has been no detailed report of complications [51. The purpose of this study is to delineate problems in technique and concept that could lower the quality of the operative outcome. Awareness of these matters could then allow for concentrated efforts to eliminate or minimize them. MATERIALS AND METHODS
One hundred conisecutive laparoscopic &olecystectomies were completed or attempted under 0 1992 Wiley-Liss, Inc.
a n Institutional Review Board Protocol in a private hospital by two surgeons. The demographics and preoperative symptoms of the patients are listed in Tables 1 and 2. All patients had extensive personal preoperative review of the technique and potential complications of the operation with the surgeon. The last 45 patients in the series watched a preoperative video designed to review the nature of the operation and better familiarize the patients with the procedure. The patients were admitted to the hospital the morning of the operation. Preoperative prophylactic antibiotics were given to 85 patients. General anesthesia was induced, and the patients were prepped and draped in standard fashion as for laparotomy. A pneumoperitoneum was obtained by instilling carbon dioxide gas through a
Accepted for publication October 7, 1991. Address reprint requests to Dr. John N. Graber, 2545 Chicago Ave. S. #600, Minneapolis, MN 55404.
Complications of Laparamopic Cholecystectomy TABLE 1. Demographics, N = 100 TABLE 3. Preoperative vs. Operative
93
Diagnoses, N = 100
Sex Male Female
N N
Age Range Average
18-80 yr 47 yr
=
=
39 61
TABLE 2. Preoperative SvmDtoms. N = 100
Diagnosis Chronic cholecystitis Cholelithiasis Acute cholecystitis Cholesterolosis Carcinoma of the gallbladder
Preoperative 100 100 0
Operative 99 86 8 17 1
were identified in these categories). In the setting of positive intraoperative cholangiograms (two patients), the cholecystectomy was completed; if the stones were >4 mm or symptomatic, a postoperative ERCP was performed (both cases). The patients were prospectively observed for complications during the operation, in the immediate postoperative period, and throughout the Verres needle placed through a periumbilical follow-up period, which extended to 26 months. puncture. A 10-mm trocar sleeve was then in- Any complications were specifically evaluated to serted into the abdominal cavity, and a 45" side- determine their precise cause. As much as possiviewing laparoscope was inserted. A cursory ex- ble, appropriate changes in the patient care and amination of the abdominal contents was technique were made to avoid further incidences accomplished, after which a cholecystcholangio- of the same complication. gram was performed by injecting 35 ml of 50% contrast into the gallbladder through a 13-gauge RESULTS needle. A second radiograph was taken after inThe preoperative diagnosis is compared with jecting another 35 ml of contrast. Residual dye was removed. Gallbladder adhesions were then the operative diagnosis in Table 3. It is not entaken down using blunt and sharp technique and tirely clear why only 86 of the 100 cases were bipolar cautery. The cystic duct was dissected, found to have stones by the pathologist; in all clipped, and divided using the contact neodym- cases, the surgeon reported identifying stones and ium:YAG (Nd:YAG) laser technique. The laser in at least six of these 14 cases, the stone(s) were was also used to remove the gallbladder from the lost and left in the intraperitoneal space. We canliver bed in a retrograde fashion. Bleeding in the not account for the absence of the stones seen by liver bed was controlled with bipolar and unipolar the pathologist in the other eight cases. Microcautery. The gallbladder was removed intact or scopic examination showed all 100 gallbladders to morselated through an 11-mm trocar sleeve. Any be pathological. Six of the 100 cases were converted to open residual intraperitoneal stones or debris were meticulously removed with cupped forceps or flushed laparotomy. In four of these six cases, it was dewith saline and aspirated; 1 g of cefazoline was cided to abandon the laparoscopic approach beadded to the irrigant. None of the fascia1 punc- cause the anatomy could not adequately be distures was extended in order to remove the gall- cerned laparoscopically. Associated pathology in bladder or stones; therefore, no sutures were these four cases was acute cholecystitis in three placed in the fascia at closure. A single intracu- cases and advanced cirrhosis in the other patient. ticular stitch was used to close the skin at each The other two cases were opened to control bleedpuncture site. Patients were discharged home ing. One was to ligate a rapidly bleeding cystic when they could ambulate without difficulty and artery in a patient found to have unsuspected carcinoma of the gallbladder. This patient required a could tolerate a regular diet. Patients who presented with signs of possi- transfusion that was considered a major complible common bile duct stones preoperatively were cation. The other was to control on going liver bed not treated differently unless they were jaundiced oozing in association with severe cirrhosis. The incidence of minor complications obor had pancreatitis, in which case a preoperative ERCP would have been performed (no patients served is listed in Table 4. Major complications SvmDtoms RUQ abdominal pain in episodes Nausea Ultrasound shows stones Asvmutomatic trallstones
N 90 75 100 0
94
Graber et al. TABLE 5. Major Complications of LaDaroscoDic Cholecvstectomv
TABLE 4. Minor Complications of Laparoscopic Cholecystectomy, N = 100 Complications Nausea lasting > 12 h Right shoulder pain (due to diaphraghmatic irritation) Right costal margin pain Puncture site complications Infection requiring I & I) at 7 days PO Infection requiring antibiotics only Prolonged site pain Excessive scarring Hematoma (minor! Subcutaneous emphysema (lasting vi
-
, , ,v Retracted , Gall Bladder Cystic Duct
,I
~,~,,, ~
Duodenum Common Duct
D. Correct
Opeking to Hepatic Duct
Hepatic Duct
Fig. 1. Mechanism of misidentification of bile ducts. A. SagittaI view of normal gallbladder and ductal anatomy. B. Distorted view of cysticlcommon duct junction due to forceful anterior retraction on the gallbladder. C. Anatomy as viewed through a laparoscope, common bile duct is misidentified as a
tions specifically associated with laser or cautery use.
long cystic duct and incorrectly encircled. D. Beginning dissection on the gallbladder, identifying the actual cysticlcommon duct junction, and viewing from different angles with a side viewing laparoscope ensures correct identification of the cystic duct.
amount of experience one has with laparoscopic technique is a major factor. Not visualizing the cystic/common duct junction takes away a major Bile Duct injuries landmark in anatomical identification. Second, forceful anterior retraction on the Of interest is the fact that both bile duct injuries in this series were not recognized until the gallbladder, as is done laparoscopically in order to patient became jaundiced 4 or 5 days later. This view the cystic duct, distorts the normal angle of speaks to the nature of the injuries; that is, they the cystic/common duct junction by straightening are not the consequence of inadvertent mechani- it out. This can falsely make the cystic and comcal trauma but instead are the result of a misin- mon duct appear as one continuous cystic duct, and the dissection is carried past the junction terpretation of the anatomy. The primary problem is misidentification of without recognizing it. Anecdotally, this seems to the cystic/common duct junction (Fig. 1).There be the most common mechanism of misidentificaare several reasons for this. First, there is reluc- tion. In conjunction with a concern that further tance to clearly dissect the junction for fear of dissection is more risky and that a “long enough” bleeding or other injury. The extent of the dissec- segment of duct has been exposed, absolute idention down the cystic duct relates to the confidence tification of the cystic/common duct junction is that a surgeon has that it can be done safely. The abandoned and the wrong duct is transected.
Graber et al. Third, the field o f view generated by the 0" vices can remove it, lack of good retraction instruviewing laparoscope is limited in that it may al- ments, and a limited number of ports available for low only one perspective. As a consequence, the the insertion of retractors, camera, and vessel occommon hepatic duct, which extends from the cluding instruments. Bleeding is such a nuisance, it is better other side of the cysticlcommon duct junction into the liver may not be seen. Not visualizing the avoided than treated. Any potential vascular common hepatic duct can only confirm a mistaken structures should be coagulated before they are impression that the common duct is the cystic cut, and all bleeding should be controlled as soon as it is observed. If the camera lens is temporarily duct. We believe that it is necessary to adhere to coated with blood, the retractors should be used several principles in order to minimize the chance on the gallbladder to compress the gallbladder itof bile duct injury. First, when dissecting the cys- self against the site of bleeding and the lens tic duct, begin on the neck of the gallbladder and cleaned, followed by step-by-step exposure of the encircle it 360" around. There is a tendency to vessel. One should start with the laparoscope pobegin dissection at an obvious and convenient site sitioned far away from the site t o see what is godistal to the gallbladder, but there is a chance ing on "at a distance"; the retractors are moved to that a structure encircled here may be the com- prevent spurting. The laparoscope is advanced to mon duct regardless of initial impressions. Once improve the view. All pooled blood is irrigated the duct is encircled at the neck of the gallblad- and aspirated and the retractors carefully moved der, progressive distal dissection can be contin- so that the vessel can be seen. Most of the time the vessel can be coagulated or clipped successfully, ued. Second, use of a laparoscope which views at but if there is any doubt about causing injury to 45" or 30" t o the side may be helpful t o allow vi- other structures such as the common hepatic duct sualization around the backside of the duct. By (as in one of our cases), the surgeon would be best rotating the scope 180", a view around the other advised t o maintain compression and convert t o side of the duct can be obtained. Newer flexible laparotomy . Heparin (2,000 U) added t o 1 L of irrigant laparoscopes offer the same advantage by elimimay help avoid the tenacious clots that are diffinating the fixed perspective of the 0" scopes. Third, dissection t o the common duct junc- cult to aspirate. For control of liver bed bleeding, tion offers the most convincing evidence of correct unipolar cautery is dramatically better than bianatomical identification. This should be accom- polar. plished t o the extent that it is technically possible Abscess Formation and safe. Lastly, cholangiography should be considClearly, the major issue in preventing an abered in all cases. A cholecystcholangiogram, as scess is t o minimize any residual debris, bilious done in this series, can be done quickly, reliably fluid collections, or hematomas. Although sterile and offers a look at the anatomy before dissection gallstones left in the peritoneal cavity have been of the cystic duct is begun [61. A cystic duct cho- shown not to cause infection in animals [41, and langiogram is done through a small ductotomy many times stones escape the surgeon both inciand would identify any errors which can then be sionally and laparoscopically without consecorrected without serious injury. Despite these quence, any such residual debris enhances the observations, we experienced two more common chance of infection. Improved techniques for rebile duct injuries within the next 200 cases. Upon moving the gallbladder and gallstones from the review of these two cases, these principles were abdominal cavity will be developed, but meticulous attention t o the removal of all debris and not adhered t o rigidly. fluid will always be important. A Silastic drain Bleeding did not prevent one of the abscesses from forming Intraoperative bleeding is part of surgery. in our series. It is unclear that prophylactic antiControl of bleeding vessels depends on the opera- biotics or antibiotic irrigation will have any effect tor's ability t o identify and expose the source and on the rate of abscess formation. We recommend then occlude the vessel. Laparoscopic exposure of copious irrigation of the right upper quadrant visa rapidly bleeding vessel is compromised by blood ceral surfaces at the conclusion of the procedure. spurting onto the scope lens, pooling blood cover- All irrigant is removed, especially along the right ing the vessel faster than the limited suction de- lateral abdominal wall adjacent to the liver. 96
Complications of Laparoscopic Cholecystectomy 97 Retained Common Duct Stones ciples, their occurrence can be minimized. Along
At the time this series was accomplished, there was no well-described technique for laparoscopic removal of common duct stones. This and improvements in technique of cholangiography have already been described [61. The major issue is identification of these common duct stones intraoperatively so that a treatment plan can be applied. For patients who have postoperative biliary tract symptoms, an immediate liver function test should be obtained and, if abnormal, consideration of ERCP. CONCLUSION
Review of the complications seen in the first 100 cases led to changes in technique and procedure that in a dramatic improvement in the incidence Of subsequent complications. duct injuries are the most Severe problems Seen in this series and, with observation of specific prin-
with other changes in technique, improvements in instrumentation will further this effort. REFERENCES 1. Graber J. The future of surgery is “less invasiveness.” J Laparoendosc Surg 1990; 157. 2. Perissat J, Collet DR, Belliard R. Gallstones: Laparoscopic treatment, intracorporcal lithotripsy followed by cholecystostomy or cholecystectomy-a personal technique. EndosCOPY 1989 21:373-374. 3. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3:131-133. 4. Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic cholecystectomy. A laboratory study. Presented a t the American Society for Laser Medicine and Surgery, Arlington, VA, April 1989 (abst). 5. Cole HM (ed): Questions and Answers: Laparoscopic cholecystectomy. JAMA 1991; 265:1585-1587. 6. Pietrafitta J, Schultz L, Graber J, Josephs L, Hickok D. Cholangiography during laparoscopic cholecystectomy: Cholecystcholangiography or cystic duct cholangiography. J Laparoendosc Surg 1991; 1:197-206.
