The Ulster Medical Journal, Volume 69, No. 2, pp. 106-111, November 2000.

Biliary complications associated with laparoscopiccholecystectomy - an analysis of common misconceptionsJ Bingham, L D McKie, J McLoughlin, T Diamond

Accepted 10 August 00

SUMMARYBackgroundSeveral views are expressed by surgeons on biliary complications following laparoscopiccholecystectomy as follow: most are caused by trainees; complications occur in the presence ofdifficult anatomy/pathology; injuries occur more proximally than at open cholecystectomy; mostinjuries are recognised immediately and most can be managed non-operatively. The aim of ourstudy was to determine if these views are substantiated in clinical practice.MethodsThe mode of presentation, management and outcome of thirty-two patients referred to ahepatobiliary unit over a seven year period were analysed.ResultsIn 72% ofcases the initial operator was a consultant. Five ofthe 32 complications (16%) occurredin the presence of difficult anatomy/pathology. Two patients had proximal biliary tree injuries,the only mortalities (two) occurring in this group. Only 41% ofinjuries were detected immediately;87% required surgical intervention, hepaticojejunostomy being the most common procedureperformed (75%).ConclusionOur study shows that the majority of bile duct injuries are not caused by trainees, do not occurbecause of unusual anatomy/pathology, do not occur in the proximal biliary tree and are notrecognised at the time of operation. Most injuries ultimately require major reconstructivesurgery for definitive management.

INTRODUCTION

Since the advent oflaparoscopic cholecystectomythere have been a large number of publicationsdiscussing the problem of biliary complications,in particular the problem of bile duct injuries.1-10Despite this, there are a number of views that areoften expressed on the subject have no support inthe literature. These include the following:

* That after the initial 'learning curve' theincidence of biliary injuries is approximatelythe same as in the 'open' era2

* That the majority are caused by traineesurgeonslI. 12

* That injuries usually occur in the presence ofunusual anatomy or difficult pathology3

* That biliary injuries are generally higher thanthose that occur with open cholecystectomy13

* That injuries are often recognised at the timeof surgery4 14

* That most complications are easily managed,and that most can be managed nonoperatively15

Based on our experience we felt that these areprobable misconceptions; therefore we reviewed

Department of Hepatobiliary Surgery, Mater Hospital,Crumlin Road, Belfast BT14 6AB.

Miss J Bingham, MB, BCh, FRCSI.Mr L D McKie, MD, FRCS.Mr T Diamond, BSc, MD, FRCS, FRCSI.

Department of Gastronterology, Mater Hospital, CrumlinRoad, Belfast BT14 6AB.

Correspondence to Mr Diamond.

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Biliary complications 107

this series of patients referred to a specialisthepatobiliary unit.

PATIENTS AND METHODS

Northern Ireland is a well defined geographicalarea with a relatively stable population of 1.6million. Over a seven-year period from 1992,thirty two patients were referred for managementofbiliary complications arising from laparoscopiccholecystectomy. In one case the initiallaparoscopic cholecystectomy had beenperformed outside Northern Ireland. There were5 male and 27 female patients with a median ageof 58 years. Seven patients were referred at thetime of initial surgery, nineteen were referred'early' (within six weeks of initial surgery) and afurther six were referred 'late' (after six weeks).Injuries were classified according to the methoddescribed by Strasberg et all (summarised inTable 1). Eight patients had Type A injuries. Inthree of these a cystic duct leak occurred as adirect consequence of an unsuspected commonbile duct stone. One patient had an injury to thesegment V duct in the gallbladder bed and theremainder of the Type A injuries were due tocystic duct necrosis or to laceration with a clip.There was one Type B injury with the commonbile duct partly occluded by a clip. Three patientshad Type C injuries, one due to a transected rightposterior sectoral duct and two due to a transectedaccessory duct. There were nine patients withTypeD injuries, all with lacerations to thecommonbile or hepatic ducts. Ten patients were referredwith Type E2 injuries. One of these occurredfollowing conversion to an open procedure fordense adhesions. Eight of the E2 injuries were'classical' laparoscopic injuries.8 One patientcould not be included in this classification. Shewas referred three years after initial surgery withrecurrent episodes of pain and jaundice due tostones in the cystic duct remnant and the commonbile duct for which she had undergone repeatedERCP. At operation she was found still to havethe distal portion of the gallbladder in-situ.Incomplete excision of the gallbladder causingthese problems has previously been described.16Where biliary reconstruction was required thiswas carried out using an 80 cm Roux-en-Y loopanastomosed to the bile duct confluence, with theanastomotic circumference increased byextending the opening along the horizontal portionofthe left hepatic duct. The anastomotic techniqueused was that described by Blumgart.'7 These

patients are all under long-term follow-up withregular measurement of liver enzymes.

RESULTS

Type A Injuries - Leakfrom minor duct (e.g. cystic ductstump) - 8 patients

None were recognised at the time ofinitial surgery.All presented in the early postoperative periodwith bile peritonitis and, in four cases, jaundiceas well. Two were managed by ERCP and stoneextraction with percutaneous drainage. One hadERCP following laparotomy and placement ofdrains. The rest had suture repair of the injury.All are alive and asymptomatic with normal liverfunction tests after follow-up ranging from 1 to64 months.Type B Injury - Occlusion ofpart ofbiliary tree by a clip- 1 patient

This patient was managed by ERCP and stenting.The stent was removed after six months and thepatient remains asymptomatic at one year withnormal liver function tests.Type C Injuries - Leakfrom accessory duct - 3 patients

One patient had a transected right posteriorsectoral duct which was recognised at the time ofinitial surgery. An immediate hepatobiliaryreferral was made and a primary repair carriedout over a T-tube. The patient was asymptomaticwith normal liver function after 30 months follow-up. The other two patients had leaks fromaccessory ducts and both presented in the earlypostoperative period with generalised biliaryperitonitis. One patient initially underwentlaparotomy at which time oversewing was carriedout, and the patient was subsequently referredbecause of a continuing bile leak. This wasmanagedby ERCP, sphincterotomy, percutaneousdrainage and drainage of a pleural effusion. Thepatient settled and had normal liver function testsafter 3 months follow-up. The other patientinitially underwent ERCP with stenting andpercutaneous drain insertion; however eventuallya laparotomy was required with the insertion of alarge bore drain for management of a bilecollection.Type D Injuries - Lateral injury to major bile ducts - 9patientsSeven patients had the injury recognised at thetime of initial surgery. One patient had a MirizziSyndrome and a tear occurred in the commonhepatic duct due to excessive traction on thegallbladder fundus. This was referred immediately

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The Ulster Medical Journal

TABLE ISTRASBERG CLASSIFICATION OF BILIARY INJ URIES

.....~~~~................. .......... ~ ~ ~ ~ ~ ..............::::::f:::: --::.-:::::::::::::::::::::.K........... ...........

......................... .n;.;,,............... Leak from Minor Duct

A i ....... ..(icntnitwih BD.8 25%.........................."X' t.................... ,

.............

................. ................................ ;.......,_:::::::::::::: :::. :::::.:F:::::::::::::::: :::::.:::::::::::::::::*:::---: :---::::-.. ::::-.:::--: -:::::--:-:::n-: :::-----:::D ::::::::::::::: ~~.........:.:.

............... ........... .. \.o.Y..,.

... ....... ......... .... ..

................... ... .......... ..

...:...eak..fro.. ....

. . . .

....;... .... ...

:-----:----.. -.. Oc l s o of:-:--t........................................ ........... .. .....................................................:::::::: ::::::::: :--::::::: T ree::::::: :--1*:: -:::-:::--:::. -:::--::.!-::---::- -::---:- -:::- .-::- -: :::::::::::::-::::::... ::::::::::::::::::...:::-::::--:: -::--::--:. --::--:--::-.. *::--::--::-:::-...--.. --..--..--.. -- -- -- -- --L. -- -- -- -

......:.atera.........to

D _...o .. .. .. .. .. ..

:................Duct....,:::::::::::::::::: :::::. d

......

............ , ,.

.....---:::----:::----:::...-:::----:::----:::----:--------:----------.. .. .. .. ..

.s............

....................^::::::::::::::::::.-.-;......:---...........................

.............. .. .. .. ..;.;.;.;.;...;.;...;.;.;.;.;.....;.-;;-;-;;.-::::::::::::::::3:::::::: 9::::::::::::::::::::4:::::::::::::::::::::::.:::::::(not in continuity: with:::CBD:;:.....:::::::::::...... :: :::r:::::::::..

:---- .....::::----- -------:::::::-s-::::::::::::::::::::::: ;:: .

: ::. ::.:.:.:.:.:.:.:.:. :. :.:.... . .

*: :-:-:-: ::: :-:-:::--:.:-:-:.:--...-:.:-:-:::;: ---::----...................... .... ........ ............

::::::::::::: ....:: :::.:.. :::--:-::-:-. .:--:::::::::::::::::::::::::::::::::: ji :::::::::: . .....

l 4 [~~~~~~~~... .ivovngrghad etdcs

...... ... .. .......

............ ....................................................

.... ........ ........., .......................

5........ Ex ivlvnthrahepatic ducts|O%|

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....................... ......

.........................

...........................................

Biliary complications 109

and the patient had a primary hepaticojejunostomycarried out with no late complications. In theremaining six a primary sutured repair had beencarried out with or without a T-tube. Two oftheserequired no further treatment and wereasymptomatic with normal liver function aftersix years and three months respectively. Theremaining four developed strictures. One ofthesehad an end to side hepaticojejunostomy performedin the same unit, before presenting later to thisunit with cholangitis due to recurrent stricturingat the site of the anastomosis. This was treated byrevision hepaticojejunostomy with revision ofthe entero-enterostomy to lengthen the Roux limb.This patient remained well with normal liverfunction after 4 years. Two patients presentedwith Bismuth type II strictures, one early and onelate. These were treated by hepaticojejunostomyand both were asymptomatic with normal liverfunction after 4 and 5 years. One further patientdeveloped a stricture but was not referred until 10months after the injury by which stage he haddeveloped a Bismuth type IV stricture andcirrhosis. Prior to referral, various inappropriatemanagement options had been attempted,including endoscopic and percutaneous balloondilatation. A hepaticojejunostomy was performedbut the patient died in the postoperative periodsecondary to DIC and liver failure.Two further patients with typeD injuries presentedin the early postoperative period with biliaryperitonitis. One developed a late stricturerequiring hepaticojejunostomy and wasasymptomatic with normal liver function after 5years follow-up. The other was referred earlywith a small puncture wound to the commonhepatic duct. A sutured repair was carried outwith no complications at 7 months.Type E Injuries - Circumferential injury to major bileducts - 10 patientsOf these, 5 were recognised at the time of surgery- one occurring after open conversion for denseadhesions. Three of these were referredimmediately at the time of initial surgery and hada hepaticojejunostomy performed as a primaryrepair. All were well with normal liver functiontests after between one and six months follow-up.Two had a sutured repair over a T-tube. One ofthese was referred early with a Bismuth type IIstricture, had a hepaticojejunostomy and waswell after 1 1 months follow-up. The otherdeveloped a Bismuth type II stricture after 2years requiring a hepaticojejunostomy.

The remaining 5 patients with type E2 injuriespresented in the early postoperative period withobstructive jaundice. All were referred early, onehaving had a laparotomy and T-tube insertionprior to referral and another having had ahepaticojejunostomy prior to referral. This patientdeveloped a dehiscence ofthe anastomosis withina few days and was referred with biliaryperitonitis. At the time of referral the patient wasrequiring ventilation, inotropic circulatorysupport and dialysis. A revision hepaticojejuno-stomy was performed to the left and right hepaticducts. There was no further bile leak ordeterioration in liver function, but the patientdeveloped progressive multi-system organ failureand died. Hepaticojejunostomies were carriedout on the remaining four patients and all werewell with normal liver function at follow upranging from 9 months to 6 years.

DISCUSSION

The aim of this paper was to examine somecommonly expressed views on laparoscopiccholecystectomy to determine if they aresupported by our data. These will be examined inturn.

Complications are no more common than in opencholecvstectomy:

Our data do not directly address this issue.However, because of the static nature of thepopulation in Northern Ireland and the fact thatthere are rarely any referrals in to or out of theregion, it is possible to form a strong impression.A previous paper from the same region reported30 patients referred over a 21 year period duringthe era of open cholecystectomy.18 Our paperreports 32 patients referred over a 7 year period.Whilst the number of cholecystectomiesperformed may have increased since the adventof laparoscopic cholecystectomy, it is veryunlikely that this can explain the apparent increasein referrals and much more likely that there hasbeen a real and significant increase in the incidenceof biliary complications.

The majority of complications are caused by traineesurgeons:

In this series the initial operator was a consultantin 23 cases (72%). Clearly, even if the procedureis carried out by a trained surgeon, the risk ofcomplications persists.

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Complications mostly occur in the presence of difficultpathology or anatomy:

It is difficult to precisely quantify these issues.However referring surgeons were asked why theythought the complication had occurred. Only onecited an anatomical variation as the cause andonly five described difficult pathology (e.gsignificant inflammation). A further threecomplications were due to unsuspected commonbile duct stones. The vast majority ofcomplications (84%) arose, therefore, in theabsence of any unusually difficult anatomy orpathology.

Biliary injuries occur more proximally in the biliary treethan at open cholecystectomy:In this series there were no patients who hadreceived type D or E injuries at or proximal to thebile duct confluence, although two patients laterdeveloped E4 type injuries. One presented verylate after persistent inappropriate attempts atmanagement by stenting, and one patient hadalready undergone hepaticojejunostomy prior toreferral. Thus, in our experience there is nothingto suggest that bile duct injuries are occurring ata higher level than in the open era. There were,however, no patients in our series with associatedvascular injuries. Other authors have noted asignificant number of cases with concomitantarterial injury and have felt that this may contributeto more proximal biliary injury.19

Most complications are recognised at the time ofsurgery:In this series 13 patients (41%) had their injuryrecognised at the time of initial surgery. Ofthe 19patients with the more serious type D and Einjuries, seven patients (78%) with type D injuries,but only five patients (50%) with type E injurieshad them recognised immediately. Overall thesedata indicate that the majority of complicationsdo not become apparent until the post-operativeperiod.

Most complications are easily managed non-operatively:In this series only four patients (13%) weremanaged without open surgery. Of 18 patientswho had a laparotomy prior to referral, 10 (56%)required a further procedure. Five patients withtype D injuries (56%) and all patients with type Einjuries required a hepaticojejunostomy. Twopatients required revision of a previoushepaticojejunostomy. The two deaths in the seriesresulted from inappropriate early managementand a delay in referral.

One of these deaths further illustrates the hazardsof attempting a definitive repair in a patientacutely ill in the early postoperative period whena period of external biliary drainage would havebeen more appropriate. Presumably some patients,particularly those with a localised bile leak weremanaged locally by ERCP and stenting, with orwithout percutaneous drainage, and ourpercentage of patients requiring open surgicalmanagement may be falsely high. Nonetheless,these data indicate that the assumption that mostcomplications are easily managed non-operativelyis false.Based on our experience and informal discussionwith the surgeons concerned, it would appear thatmany of these complications were avoidable,given that eight of the injuries were 'classical'. Acareful review of the anatomy prior to dividingany duct is an essential step of laparoscopiccholecystectomy. Earlier conversion to opensurgery in the face of difficult dissection,unexpected findings or suspected biliary injurywould probably have prevented or minimisedmany of the complications discussed. This isdespite the fact that one bile duct injury in thisseries occurred after conversion.It is therefore important to remember that evenafter conversion, the factor making the procedurerisky or difficult may still be present and thesurgeon must maintain a high level ofcaution andsafety. Wecould notrecommend a 'no-conversionpolicy' as advocated by some.20 The role ofroutinecholangiography remains unclear and there areno appropriate prospective randomised trials ofits effectiveness, although one recent retrospectivestudy suggested that it did significantly reducethe risk of injury.2' Only one patient in our serieshad a cholangiogram and this did not prevent amajor injury from occurring. It is possible thatcholangiography may have allowed earlieridentification of biliary injuries, and may haveprevented the three complications in this seriesthat occurred due to unsuspected common bileduct stones.In conclusion, an analysis of our experience hasproved useful in addressing a number ofcommonmisconceptions regarding the occurrence ofbiliary complications following laparoscopiccholecystectomy. In addition we have shownthat, with prompt referral, a successful outcomecan be obtained for the majority of patients.Delay in referral and persistent attempts atinappropriate management can be catastrophic.

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C) The Ulster Medical Society, 2000.