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Causes of Biliary Injury in LC
Failure to properly occl. the cystic ductInjury to the ducts in the liver bed caused by entering a plane too deep to the gallbladderCautery Misuse thermal necrosis ductaltissue loss
Pulling forcefully up on the gallbladder whenclipping the cystic duct tenting injury to thejunction of the CBD & common hepatic duct
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Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury
during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) : 101-25.
Reviews revealed the incidence of biliary injury during open CCY to be 0.1-0.3%1995 Strasbergs study which incl. more than124,000 laparoscopic cholecystectomies (LC)reported in the literature found the incidence of major bile duct injury to be 0.5%.
Biliary Injuries DuringCholecystectomy (CCY)
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The Effect of Acute Cholecystitison Biliary Injury
The incidence of bile leakage after emergency LC for acute cholecystitis is higher than that forelective.
1.37% in acute chole v. 0.09% in elective
n = 3300 (10yrs); retrospective (Taipei)
Lien et al. Management of bile leakage after LC based onetiologic classification. Surg Today (2004) 34:326 330
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Diagnosis of Bile Leaks
Persistent fullness, anorexia, abdominal pain,fever & tenderness,jaundice, elev WBCHigh level of suspicion following surgery Bile draining from a drain left in the operativefield
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Radiographic Diagnosis of BiliaryInjury
US/CT detect bilomas (poss. perc drainage)
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Radiographic Diagnosis of BiliaryInjury
US/CT detect bilomas (poss. perc drainage)HIDA presence of active bile leak (physiologic)MRCP demonstrate dilated/stenotic biliary tract; retained stones..not physiologic northerapeutic
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ERCP
Provides exact anatomical diagnosis of bile ductleak; while allowing treatment w/decompression of the biliary tree.Principal of treatment is to establish a pressuregradient that will favor flow into the duodenumnot the leak site; may entail removal of retainedstone or internal stenting +/- sphincterotomy
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Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D)
Cessation of bile extravasation in 70-95% of cases w/in 7 days
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Detection in post-op period
Abx, nutrition support, percutaneous drainageof bile collex (US or CT)MRCP, PTC or ERCP to delineate location of injury.
Once sepsis and leaks are controlled, then may perform definitive reconstruction w/ R-Y hepaticojejunostomy
Kaman et al. Management of Major Bile Duct Injuries
following LC. Surg Endosc (2004)18:1196 1199
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