Bile duct injuries in Laparocsopic cholecystectomy

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This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.

Transcript of Bile duct injuries in Laparocsopic cholecystectomy

  • 1. Biliary Injuries During Laparoscopic Cholecystectomy Dr.Atul kumar Mishra M.S (Gen.Surgery)
  • 2. Historical perspective First planned cholecystectomy in the world was performed by Carl Langenbuch in 1882. First choledochotomy was performed by Couvoisser in 1890. First iatrogenic bile duct injury was described by Sprengel in 1891. Prof. Dr. Med Erich Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy in 1985.
  • 3. Biliary Anatomy a. Right hepatic duct. b. Left hepatic duct. c. Common hepatic duct. d. Portal vein. e. Hepatic artery. f. Gastroduodenal artery. g. Right gastroepiploic artery. h. Common bile duct. i. Fundus of the gallbladder. j. Body of the gallbladder. k. Infundibulum. l. Cystic duct. m. Cystic artery. n. Superior pancreaticoduodenal artery. Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
  • 4. Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said that anomalies are rule, not the exception. ( Maingots abdominal operations) Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy
  • 5. Anatomy Calot's triangle bounded by cystic duct, cystic artery, and common hepatic duct. Hepatocystic triangle bounded by gallbladder wall and cystic duct, liver edge, and common hepatic duct; the cystic artery (and hence Calot's triangle) lies within this space. (Maingots abdominal operation)
  • 6. Aim of the laparoscopic cholecystectomy Surgery (TODAY)->Discharge on same/next day Complicated / Injury Long hospital stay Repeated investigations like USG and ERCP Radiologic interventions Re-operations
  • 7. Laparoscopic cholecystectomy Pros and cons General advantages Shorter stay in hospital Faster recovery period Reduced post-op recovery time Less postoperative pain Improved cosmetic outcome Disadvantage Increase in serious bile duct and injuries complications
  • 8. Operating Room Setup Reverse Trendelenburg (30 degrees) with left arm out at 90 degrees relative to the bodys axis Titled left 15 degrees after optical trocar placement
  • 9. Epigastric region, below XP Trocar Placement Subcostal, MidClavicular Mid-A, between 12th rib and iliac crest Umbilical region
  • 10. Introduction Open cholecystectomy was standard practice for treatment of symptomatic gall bladder disease until late 1980s. At present 90% of cholecystectomies performed by LC which is one of the commonest surgical procedure in world. Unfortunately, widespread application of LC led to concurrent rise in incidence of major bile duct injuries (BDI),which are more complicated than after open procedures. Since its introduction and routine use in 1990s, the incidence of biliary injuries has doubled from 0.2% to 0.4% and remained constant despite advances in knowledge, technique, and technology.
  • 11. Classic Laparoscopic Injury Mistaking common bile duct for the cystic duct
  • 12. Thermal Injuries Inappropriate use of electrocautery near biliary ducts May lead to stricture and/or bile leaks Mechanical trauma can have similar effects Lahey Clinic, Burlington, MA.1994
  • 13. Bile duct injuries during cholecystectomy In 1990s, high rate of biliary injury was due to learning curve effect. Surgeon had 1.7% chance of a bile duct injury occuring in first case and 0.17% at the 50th case. However most surgeons passed through learning curve, steady state reached, but there has been no significant improvement in the incidence of biliary duct injuries.
  • 14. Biliary Injuries during Cholecystectomy Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative Biliary tract injuries. On other hand LC has been associated with 2.5fold to 4-fold increase in the incidence of postoperative BDI compared with OC.
  • 15. These preventable injuries can be devastating, increasing morbidity, mortality, and medical cost, while decreasing the patients quality of life. Biliary injuries will always exist, and we need to be aware of the best methods to avoid, evaluate, and treat them.
  • 16. Incidence of IBDI following cholecystectomy (%) Author IBDI incidence following OC IBDI Incidence following LC Mc Mohan et al,1995 0.2 0.81 Strassberg et al, 1995 0.07 0.5 Shea et al,1996 0.19-0.29 0.36-0.47 Targarona et al, 1998 0.6 0.95 Lillemoe et al, 2000 0.3 0.4-0.6 Gazzaniga et al, 2001 0.0-0.5 0.07-0.95 Savar et al,2004 0.18 0.21 Moore et al,2004 0.2 0.4 Misra et al,2004 0.1-0.3 0.4-0.6 Gentileschi et al,2004 0.0-0.7 0.1-1.1 Kaman et al,2006 0.3 0.6
  • 17. Risk Factors for Biliary tract injury Surgeon related factors Lack of experience (learning curve) Misidentification of biliary anatomy Intraoperative bleeding Lack of recognition of anatomical variations of biliary tree Improper interpretation of IOC Improperly functioning equipment
  • 18. Risk for biliary tract injury Patient related Acute and chronic cholecystitis Empyema Long standing recurrent disease -> fibrosis Porcelain gallbladder Obesity Previous surgery Male sex Advanced age
  • 19. The Effect of Acute Cholecystitis on Lap. cholecystectomy complications Complication rate three times greater than for elective LC. Early cholecystectomy (72 h) outcome better than delayed cholecystectomy. Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9%.
  • 20. Risk Factors for biliary tract injuries Anatomic Variations Present in 18 39% cases Dangerous variations predisposing to BTI are present in only 3-6% of cases Abnormal biliary anatomy Short cystic duct, cystic duct entering in the right ductAccessory right hepatic duct Arterial anomalies Right hepatic artery running parallel to the cystic duct Anomalous or accessory right hepatic artery
  • 21. (Sabiston text book of surgery 19thedtn.)
  • 22. Summary of Causes of Bile Duct Injuries Misidentification of Common bile duct Common hepatic duct An aberrant duct (usually on the right side) Technical failure such as Slippage of clips placed on the cystic duct Inadvertent thermal injury to CBD Tenting of CBD during clip placement Disruption of a bile duct entering directly into gallbladder fossa . (Goal of dissection should be conclusive identification of cystic structure within Calot triangle) (If the cystic duct and cystic artery are conclusively and correctly identified before dividing, more than 70% of bile duct injuries would be avoided )
  • 23. Technique Four methods of identification of cystic structures during cholecystectomy 1) Routine cholangiography 2) Critical view technique 3) Infundibular technique-> widely used 4) Dissection of main bile duct with visualization of cystic