Bile Duct Injury After Single Incision
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Bile Duct Injury After Single IncisionLaparoscopic Cholecystectomy
Kwan N. Lau, MD, David Sindram, MD, PhD, Neal Agee, MD,John B. Martinie, MD, David A. Iannitti, MD
Background: The advancement and development oflaparoscopic cholecystectomy revolutionized surgery andcase management. Many procedures are routinely per-formed laparoscopically. Single incision laparoscopic sur-gery has been introduced with the hope of further reduc-tion of scarring and possibly procedural pain. With noestablished technique for this procedure, the safety ofsingle incision laparoscopic cholecystectomy has notbeen determined.
Methods and Results: A 30-year-old man underwentsingle incision laparoscopic cholecystectomy for symp-tomatic cholelithiasis at an outside hospital. The operationwas uneventful, and the patient was discharged home.The patient returned to the Emergency Department 4 dayspostoperatively, and a bile duct injury was diagnosed. Apercutaneous drain was placed, and the patient was trans-ferred to the Hepato-Pancreato-Biliary (HPB) service of atertiary care center for definitive care. A delayed repairapproach was used to allow the inflammation around theporta to decrease. Six weeks after injury, the patient un-derwent Roux-en-Y hepaticojejunostomy. The patient didwell postoperatively.
Conclusion: Although single incision laparoscopic sur-gery will play a prominent role in the future, its develop-ment and application are not without risks as demon-strated from this case. It is imperative that surgeons betterdefine the surgical approach to achieve the critical viewand select appropriate patients for single incision laparo-scopic cholecystectomy.
Key Words: Single incision laparoscopic cholecystec-tomy, Bile duct injury.
The advancement and development of laparoscopic cho-lecystectomy revolutionized surgery and case manage-ment. Many procedures, such as adrenalectomy, colec-tomy, hernia repair, and cholecystectomy are routinelyperformed laparoscopically. Open cholecystectomy hasbeen largely replaced by laparoscopic cholecystectomysince the first reported case in 1987.1 As technologiesevolve, surgeons continue to improve perioperative pa-tient outcomes by introducing various methods to reduceport size and number. This pursuit of scarless surgeryhas given rise to the concept of Natural Orifice Translu-minal Surgery (NOTES) and single incision laparoscopicsurgery. These approaches might offer significant advan-tages for minimizing procedural pain and eliminating orminimizing postoperative scars, while maintaining thesame safety profiles and cost effectiveness. While thecurrent standard approach for cholecystectomy is laparo-scopic cholecystectomy by a multi-port minimally inva-sive technique, scattered series in the literature have alsodescribed the early experiences of patients undergoingsingle incision for cholecystectomy.28 Although it is pre-mature to determine the complication rate from singleincision laparoscopic cholecystectomy due to the smallnumber of reported cases, one report suggests that thecomplication rate may be as high as 16.6%.9 However, incontrast to laparoscopic cholecystectomy, no significantinjury involving the porta hepatis has been reported fol-lowing a single incision laparoscopic cholecystectomy.We report the first bile duct injury from single incisionlaparoscopic cholecystectomy.
The patient is a 30-year-old man who underwent singleincision laparoscopic cholecystectomy at an outside hospital.The patients operation was reportedly uncomplicated, andthe patient was discharged the same day. The patient devel-oped abdominal pain and fever on postoperative day 4 andsought medical attention. Technetium-99m dimethyl acetan-ilide iminodiacetic acid hepatobiliary (HIDA) scan demon-strated a biliary leak. The patients management included acomputed tomography (CT), percutaneous drainage of bi-loma (Figure 1), and an endoscopic retrograde cholangio-
HPB Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Depart-ment of General Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA(all authors).
Address correspondence to: David A. Iannitti, MD, Program Director, Hepato-Pancreato-Biliary Surgery, Division of Gastrointestinal and Minimally Invasive Sur-gery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd. MEB 601,Charlotte, NC, 28203, USA. Telephone: (704) 355-6220, Fax: (704) 355-4822, E-mail:David.Iannitti@carolinashealthcare.org
2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published bythe Society of Laparoendoscopic Surgeons, Inc.
JSLS (2010)14:587591 587
pancreatography (ERCP). The CT revealed diminution ofenhancement throughout the right lobe of the liver, and thisfinding was consistent with a right hepatic artery ligation. AnERCP demonstrated complete occlusion of the common bileduct with no communication to the proximal intrahepaticductal system (Figure 2). The percutaneous drain continuedto drain bile, and the patient was transferred to the HPBservice of a tertiary care center for definitive treatment of acommon bile duct injury.
A delayed repair approach was chosen to allow the in-flammatory tissue involving the porta to decrease anddelayed biliary injury to manifest due to vascular compro-mise. Six weeks after the injury, the patient was explored.Intraoperatively, the injury was identified at the hilus ofthe liver. The common bile duct was divided at the con-fluence of the left and right hepatic ducts, and the distalduct was clip ligated. The left hepatic duct was openedtransversely through the confluence (Figures 3 and 4).The right anterior sector and the right posterior sectorducts were then identified with coronary probes. The rightposterior sector duct was identified as the dominantbranch. A handsewn end-to-side hepaticojejunostomywas performed in an interrupted fashion with 5-0 PDSsuture. The patient had an uneventful postoperativecourse and was discharged home on postoperative day 5.
It is well established that conventional laparoscopic cho-lecystectomy following the guideline of critical view re-sults in major bile duct or vessels injury in1% of patients(range, 0.3 to 0.95) with other complications 3%.1013
The relative safety associated with laparoscopic cholecys-tectomy has led to its acceptance as the gold standard forcholecystectomy. Significant factors contributing to the
Figure 1. Computed tomography showing a subhepatic biloma(arrow).
Figure 2. Ligation of distal common bile duct with no filling ofthe proximal common bile duct. Clip at the common bile duct(arrow).
Figure 3. Intraoperative picture of the porta hepatis showingtransection of the bile ducts at their confluence (arrow).
Bile Duct Injury After Single Incision Laparoscopic Cholecystectomy, Lau KN et al.
safety may be standardized technique involving carefuldissection of the triangle of Calot with development of thecritical view of safety, experience with laparoscopic cho-lecystectomy and other laparoscopic procedures, im-provement in the laparoscopic instruments,14 and routineuse of cholangiography.
Since the introduction of laparoscopic cholecystectomy,the evolution of minimally invasive techniques has con-tinued the search for a less invasive and painful procedurewith an emphasis on decreasing the number, size, or bothnumber and size, of the trocars. This has subsequently ledto the development of a single, commercially available,multi-instrument plastic cylinder. The single incision lapa-roscopic port is usually inserted through a small umbilicalincision and provides excellent postoperative cosmesis.15
However, cosmesis alone may not be sufficient to justifythe potential operative risks from single incision laparo-scopic cholecystectomy. Others have suggested that pa-tients may have less postoperative pain from singleincision laparoscopic surgery. No data currently existcomparing postoperative pain from single incision lapa-roscopic cholecystectomy with that of conventional lapa-roscopic cholecystectomy. Port reduction strategies havepreviously led to the development of a minilaparoscopicapproach, where minilaparoscopy is defined as 2-portlaparoscopic surgery with a standard size umbilical portand a 2-mm, lateral mini-port. A metaanalysis comparing
minilaparoscopic cholecystectomy with conventional lapa-roscopic cholecystectomy failed to demonstrate significantimprovements in surgical outcomes, including pain.16 Suchdata for single incision laparoscopic cholecystectomy arecurrently lacking.
Recently, Chamberlain et al17 performed a comprehensivereview of case series using single incision laparoscopiccholecystectomy. Of the reported cases, 142 cholecystec-tomies were attempted by single incision laparoscopictechnique; 130 of these cholecystectomies were comple-ted.8,9,1825 Ten operations were converted to open casesdue to difficult dissection or cystic artery hemorrhage. Themajority of the patients were highly selected young peoplewith cholelithiasis. Minor complications including subcuta-neous hematoma and bile leak were reported with the com-plication rate ranging from 0% to16%.9 No major bile ductinjury was reported in this study.
The experience transitioning from open cholecystectomyto laparoscopic cholecystectomy has taught us that a min-imum of 12 cases is necessary to decrease the complica-tion rate for laparoscopic cholecystectomy.26 Similarly, theinitial learning curve may result in an increased compli-cation rate for single incision laparoscopic cholecystec-tomy. The minimum number for single incision laparo-scopic procedures has yet to be determined. Since mostsurgeons performing single incision laparoscopic chole-cys