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IATROGENIC BILE DUCT INJURIESDR RAJNEESH VARSHNEYMS, DNB

SURGICAL GASTROENTEROLOGIST

SRMSIMS, BAREILLY

Widespread acceptance in early 1990s Gold Standard treatment for gallbladder removal General advantages of LCMIS approachReduced hospitalization Improved recovery time Decreased PO pain Improved cosmesis Reduced cost

LC has been associated with a higher incidence of IA bile duct injuries

LC0.4 to 0.8% Traditional OC0.1-0.3%

Association:

Increased mortality and morbidity Reduced long-term survival Reduced quality of life

Infrequentbut among the leading sources of malpractice claims against surgeons. Between 34% and 49% of surgeons are expected to cause such an injury during their career. Awareness and preventative methods are of clinical importance to surgeons.

Risk FactorsAnatomical Anatomical variations (biliary and vasculature) Bleeding, scarring, obesity Laparoscopic Lack of Depth Perception, Tactile Feedback, Full Manual Maneuverability Improper surgical approach Improper Lateral retraction (insufficient or excessive) 0 degree scope Approach plane too deep

Lack of conversion to OC during difficult cases

Anatomical Misidentification: excision, incision, or transection of biliary anatomy Injuries: common bile duct, common hepatic duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments Anatomical variations (biliary and vasculature)

Electrocautery, thermal injury: stricture of CBD or hepatic ducts, bile leak Mechanical trauma: stricture of the biliary ducts, bile leaks

--Mistaking the common bile duct for the cystic duct

PATTERNS OF BILIARY TRACT 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

Type A Cystic duct leaks or leaks from small ducts in the liver bed Type B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts Type C Transection without ligation of the aberrant right hepatic ducts Type D Lateral injuries to major bile ducts Type E Subdivided as per Bismuth classification into E1 to E5

E: injury to main duct (Bismuth)E1: Transection >2cm from confluence E2: Transection