Br. J. Surg. 1991, Vol. 78, December, 1412-1413
Iatrogenic injury to the bile duct Trauma to the extrahepatic biliary tree can result from a number of medical and surgical procedures, but it is the 'accidental' injury arising at cholecystectomy which most frequently results in tragic consequences for patients, who may be deprived of their most productive years of life. This type of injury may necessitate repeated surgical intervention, the morbidity and mortality rates of which far exceed those of the original procedure. Damage to the bile ducts at operation is preventable because it results from a failure of surgical technique. There is debate about the exact incidence of bile duct injury at cholecystectomy; the few surveys undertaken have put the figure at one injury per 300-500 open cholecystectomy procedures'*2. Biliary surgery has, of course, undergone a resurgence of interest in the past few years with the advent of laparoscopic removal of the gallbladder. Although some authors have speculated that there has been a tenfold increase in the incidence of trauma to the extrahepatic biliary tree with this new technique3, the early published series show only a slight increase in incidence to one injury per 150-200 laparoscopic cholecyste~tomies~-~. The true frequency of injury may be greater but unrecognized, because of under-reporting and lack of adequate long-term follow-up of patients in whom such trauma may declare itself as a stricture only some years after the original surgery. However, this is true for both open and laparoscopic cholecystectomy, and the risk of injury from the latter procedure might not be as great as some have feared. In any event, pressure to remove the gallbladder employing a minimally invasive technique will continue to be patient driven. Bile duct injury results from imprecise dissection and inadequate demonstration of the anatomical structures. The wide variation in biliary anatomy is often cited as a contributing factor to the development of such injuries, particularly where dissection is difficult in patients whose gallbladder is fibrosed from previous attacks of acute cholecystitis. The extrahepatic biliary tree is most at risk in those patients in whom there is a low entry of a right hepatic sectoral duct into the common bile duct. Injury to the common hepatic duct may result from injudicious attempts by the surgeon to control haemorrhage, although anomalies of the vasculature are not always responsible. Protagonists of operative cholangiography have suggested that this investigation will minimize the risk of damage to the extrahepatic biliary tree by providing an accurate record of the biliary anatomy. In a review of a personal series of patients managed for such trauma, Blumgart7 noted that only 29 per cent of these had undergone operative cholangiography at the time of their original surgery. However, in an extensive review of bile duct injury in Sweden, where operative cholangiography was undertaken routinely, Andren-Sandberg and colleagues' noted that 44 per cent of bile duct injuries occurred before the cystic duct was cannulated and a further 52 per cent arose before the operative cholangiogram films were reviewed by the surgeon. Operative cholangiography is no substitute for careful dissection and identification of the ductal structures, but when undertaken properly this procedure may reduce the risk of damage to the bile duct. Furthermore, early recognition of the injury by cholangiography will ensure prompt referral for specialist advice. It is apparent from the results of open cholecystectomy that the experienced surgeon is not immune from traumatizing the extrahepatic biliary tree, although it is more likely that this complication will arise between the surgeon's 25th and 100th open cholecystectomy'. The learning curve for laparoscopic cholecystectomy has yet to be determined and it remains to be seen whether the bile duct is at most risk during the 'easy', straightforward operation, which some believe to be the case for open cholecystectomy'. The bile duct may be more liable to damage because of the use of diathermy in laparoscopic dissection, and so it may not be justified for the surgeon to undertake extensive dissection of the cystic duct to identify its confluence with the hepatic duct. Furthermore, such dissection may jeopardize the delicate microcirculation of the biliary tree and so produce ischaemic necrosis with subsequent stricture formation'. There is some debate as to whether absorbable clips or ligatures should be employed instead of titanium clips to secure the cystic duct, but there are no data from early reports of laparoscopic cholecystectomy to indicate that this should be a major concern. At open cholecystectomy, injury to the bile duct may go unrecognized and declare itself as a biliary fistula or as jaundice only in the postoperative period. Routine abdominal drainage may allow early detection of bile leakage and avoid the extensive
~
1412
0007-1323,91,12 1412-02
c
1991 Butterworth-Heinemann Ltd
Leading articles
morbidity and mortality associated with biliary peritonitis. Although a policy of routine drainage after open cholecystectomy has found little support, such an approach may be valuable after laparoscopic cholecystectomy to avoid the early discharge of a patient with an occult bile leak which would clearly benefit from careful observation and further evaluation. If the injury is recognized at surgery and there is no loss of duct, it may be managed by insertion of a T tube or by primary anastomosis without tension of the tissues. It is more likely, however, that a Roux loop ofjejunum will require to be anastomosed to the common hepatic duct, but the inexperienced surgeon should refrain from undertaking unfamiliar manoeuvres which aggravate the situation. The outcome of secondary repair in the patient with an established biliary fistula is less favourable because of the small calibre of the hepatic ducts ; optimum results are obtained in the jaundiced patient with a dilated duct system. Considerable patience will therefore be required of both the patient and surgeon to enable controlled closure of an external biliary fistula before repair is undertaken. The best chance of effecting a successful repair is at the initial attempt by a skilled surgeon. Experience suggests that the most successful method of reconstruction is by direct mucosa-to-mucosa suture of the hepatic duct to a Roux loop of jejunum". In the past, the 'mucosal graft' technique has been advocated where no duct stump remains", but it is unusual not to be able to effect an anastomosis to the left hepatic duct, which runs an extrahepatic course and can be exposed by careful dissection of adhesions in the gallbladder bed, in the region of the ligamentum teres and on the inferior aspect of the caudate lobe. Repeated surgical intervention in such circumstances meets with a diminishing return. The use of percutaneous or endoscopic manoeuvres should be restricted to frail patients unfit for anaesthesia, since such procedures are unlikely to provide long-lasting freedom from symptoms. Patients in whom satisfactory repair is not effected may experience recurrent attacks of cholangitis and jaundice which may progress to produce secondary biliary cirrhosis and portal hypertension. Treatment will then centre on the management of liver failure and sepsis. Liver transplantation in these patients is hazardous, but must inevitably be considered because of the benign nature of the underlying disease and the cause of the initial injury. It would, however, be unfortunate for any patient to be exposed to the full breadth of hepatobiliary surgery from laparoscopic cholecystectomy to liver replacement !
0.J. Garden University Department of Surgery Royal Infirmary I Lauriston Place Edinburgh EH3 9 Y W UK 1.
2.
3. 4.
5.
6.
Bismuth H . Post-operative strictures of the bile duct. I n : Blumgart LH, ed. The Biliary Tract. Clinical Surgery International. Vol. 5 . Edinburgh: Churchill Livingstone, 1982: 209-18. Kune GA. Bile duct injury during cholecystectomy. Causes, prevention and surgical repair in 1979. Ausi NZ J Surg I979 ; 49 35-40. Cameron JL, Gadacz TR. Laparoscopic surgery. Ann Sury 1991; 213: 1-2. Peters JH, Ellison GC, Innes JT ef ul. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann Sury 1991; 213: 3-12. Mayers WC. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991 ; 324: 1073-8. Cuschieri A, Dubois F, Mouiel J et a / . The European experience with laparoscopic
Br. J . Surg., Vol. 78, No. 12, December1991
7.
8.
9.
10.
11.
cholecystectomy. Am J Sury 1991; 161: 385-7. Blumgart LH. Benign biliary strictures. In : Blumgart LH, ed. Surgery of the Liver and Biliary Tract. Vol. I . Edinburgh : Churchill Livingstone, 1988: 721-52. Andren-Sandberg A, Alindeer G , Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. Ann Sury 1985; 201: 328-32. Northover JMA, Terblanche J. A new look at the arterial blood supply of the bile duct in man and its surgical implications. Br J Sury 1979; 66: 379-84. Bismuth H, Franco D, Corlette MB, Hepp J . Long-term results of Roux-en-Y hepaticojejunostomy. Sury Gynecol Obstet 1978; 146: 161-7. Smith R. Obstructions of the bile duct. Br J Sury 1979; 66: 69-79.
1413
Iatrogenic injury to the bile duct Trauma to the extrahepatic biliary tree can result from a number of medical and surgical procedures, but it is the 'accidental' injury arising at cholecystectomy which most frequently results in tragic consequences for patients, who may be deprived of their most productive years of life. This type of injury may necessitate repeated surgical intervention, the morbidity and mortality rates of which far exceed those of the original procedure. Damage to the bile ducts at operation is preventable because it results from a failure of surgical technique. There is debate about the exact incidence of bile duct injury at cholecystectomy; the few surveys undertaken have put the figure at one injury per 300-500 open cholecystectomy procedures'*2. Biliary surgery has, of course, undergone a resurgence of interest in the past few years with the advent of laparoscopic removal of the gallbladder. Although some authors have speculated that there has been a tenfold increase in the incidence of trauma to the extrahepatic biliary tree with this new technique3, the early published series show only a slight increase in incidence to one injury per 150-200 laparoscopic cholecyste~tomies~-~. The true frequency of injury may be greater but unrecognized, because of under-reporting and lack of adequate long-term follow-up of patients in whom such trauma may declare itself as a stricture only some years after the original surgery. However, this is true for both open and laparoscopic cholecystectomy, and the risk of injury from the latter procedure might not be as great as some have feared. In any event, pressure to remove the gallbladder employing a minimally invasive technique will continue to be patient driven. Bile duct injury results from imprecise dissection and inadequate demonstration of the anatomical structures. The wide variation in biliary anatomy is often cited as a contributing factor to the development of such injuries, particularly where dissection is difficult in patients whose gallbladder is fibrosed from previous attacks of acute cholecystitis. The extrahepatic biliary tree is most at risk in those patients in whom there is a low entry of a right hepatic sectoral duct into the common bile duct. Injury to the common hepatic duct may result from injudicious attempts by the surgeon to control haemorrhage, although anomalies of the vasculature are not always responsible. Protagonists of operative cholangiography have suggested that this investigation will minimize the risk of damage to the extrahepatic biliary tree by providing an accurate record of the biliary anatomy. In a review of a personal series of patients managed for such trauma, Blumgart7 noted that only 29 per cent of these had undergone operative cholangiography at the time of their original surgery. However, in an extensive review of bile duct injury in Sweden, where operative cholangiography was undertaken routinely, Andren-Sandberg and colleagues' noted that 44 per cent of bile duct injuries occurred before the cystic duct was cannulated and a further 52 per cent arose before the operative cholangiogram films were reviewed by the surgeon. Operative cholangiography is no substitute for careful dissection and identification of the ductal structures, but when undertaken properly this procedure may reduce the risk of damage to the bile duct. Furthermore, early recognition of the injury by cholangiography will ensure prompt referral for specialist advice. It is apparent from the results of open cholecystectomy that the experienced surgeon is not immune from traumatizing the extrahepatic biliary tree, although it is more likely that this complication will arise between the surgeon's 25th and 100th open cholecystectomy'. The learning curve for laparoscopic cholecystectomy has yet to be determined and it remains to be seen whether the bile duct is at most risk during the 'easy', straightforward operation, which some believe to be the case for open cholecystectomy'. The bile duct may be more liable to damage because of the use of diathermy in laparoscopic dissection, and so it may not be justified for the surgeon to undertake extensive dissection of the cystic duct to identify its confluence with the hepatic duct. Furthermore, such dissection may jeopardize the delicate microcirculation of the biliary tree and so produce ischaemic necrosis with subsequent stricture formation'. There is some debate as to whether absorbable clips or ligatures should be employed instead of titanium clips to secure the cystic duct, but there are no data from early reports of laparoscopic cholecystectomy to indicate that this should be a major concern. At open cholecystectomy, injury to the bile duct may go unrecognized and declare itself as a biliary fistula or as jaundice only in the postoperative period. Routine abdominal drainage may allow early detection of bile leakage and avoid the extensive
~
1412
0007-1323,91,12 1412-02
c
1991 Butterworth-Heinemann Ltd
Leading articles
morbidity and mortality associated with biliary peritonitis. Although a policy of routine drainage after open cholecystectomy has found little support, such an approach may be valuable after laparoscopic cholecystectomy to avoid the early discharge of a patient with an occult bile leak which would clearly benefit from careful observation and further evaluation. If the injury is recognized at surgery and there is no loss of duct, it may be managed by insertion of a T tube or by primary anastomosis without tension of the tissues. It is more likely, however, that a Roux loop ofjejunum will require to be anastomosed to the common hepatic duct, but the inexperienced surgeon should refrain from undertaking unfamiliar manoeuvres which aggravate the situation. The outcome of secondary repair in the patient with an established biliary fistula is less favourable because of the small calibre of the hepatic ducts ; optimum results are obtained in the jaundiced patient with a dilated duct system. Considerable patience will therefore be required of both the patient and surgeon to enable controlled closure of an external biliary fistula before repair is undertaken. The best chance of effecting a successful repair is at the initial attempt by a skilled surgeon. Experience suggests that the most successful method of reconstruction is by direct mucosa-to-mucosa suture of the hepatic duct to a Roux loop of jejunum". In the past, the 'mucosal graft' technique has been advocated where no duct stump remains", but it is unusual not to be able to effect an anastomosis to the left hepatic duct, which runs an extrahepatic course and can be exposed by careful dissection of adhesions in the gallbladder bed, in the region of the ligamentum teres and on the inferior aspect of the caudate lobe. Repeated surgical intervention in such circumstances meets with a diminishing return. The use of percutaneous or endoscopic manoeuvres should be restricted to frail patients unfit for anaesthesia, since such procedures are unlikely to provide long-lasting freedom from symptoms. Patients in whom satisfactory repair is not effected may experience recurrent attacks of cholangitis and jaundice which may progress to produce secondary biliary cirrhosis and portal hypertension. Treatment will then centre on the management of liver failure and sepsis. Liver transplantation in these patients is hazardous, but must inevitably be considered because of the benign nature of the underlying disease and the cause of the initial injury. It would, however, be unfortunate for any patient to be exposed to the full breadth of hepatobiliary surgery from laparoscopic cholecystectomy to liver replacement !
0.J. Garden University Department of Surgery Royal Infirmary I Lauriston Place Edinburgh EH3 9 Y W UK 1.
2.
3. 4.
5.
6.
Bismuth H . Post-operative strictures of the bile duct. I n : Blumgart LH, ed. The Biliary Tract. Clinical Surgery International. Vol. 5 . Edinburgh: Churchill Livingstone, 1982: 209-18. Kune GA. Bile duct injury during cholecystectomy. Causes, prevention and surgical repair in 1979. Ausi NZ J Surg I979 ; 49 35-40. Cameron JL, Gadacz TR. Laparoscopic surgery. Ann Sury 1991; 213: 1-2. Peters JH, Ellison GC, Innes JT ef ul. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann Sury 1991; 213: 3-12. Mayers WC. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991 ; 324: 1073-8. Cuschieri A, Dubois F, Mouiel J et a / . The European experience with laparoscopic
Br. J . Surg., Vol. 78, No. 12, December1991
7.
8.
9.
10.
11.
cholecystectomy. Am J Sury 1991; 161: 385-7. Blumgart LH. Benign biliary strictures. In : Blumgart LH, ed. Surgery of the Liver and Biliary Tract. Vol. I . Edinburgh : Churchill Livingstone, 1988: 721-52. Andren-Sandberg A, Alindeer G , Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. Ann Sury 1985; 201: 328-32. Northover JMA, Terblanche J. A new look at the arterial blood supply of the bile duct in man and its surgical implications. Br J Sury 1979; 66: 379-84. Bismuth H, Franco D, Corlette MB, Hepp J . Long-term results of Roux-en-Y hepaticojejunostomy. Sury Gynecol Obstet 1978; 146: 161-7. Smith R. Obstructions of the bile duct. Br J Sury 1979; 66: 69-79.
1413
