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DR RAJNEESH VARSHNEY
MS, DNB
SURGICAL GASTROENTEROLOGIST
SRMSIMS, BAREILLY
Widespread acceptance in early 1990s Gold Standard treatment for gallbladder removal General advantages of LCMIS approach
Reduced hospitalization Improved recovery time Decreased PO pain Improved cosmesis Reduced cost
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 Factors
Anatomical 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
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
Inappropriate use of electrocautery near biliary ducts May lead to stricture and/or bile leaks Mechanical trauma can have similar effects
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
Type 1 Leaks from cystic duct stump or small ducts in liver bed Type 2 Partial CBD/CHD wall injuries without (2A) or with (2B) tissue loss Type 3 CBD/CHD transection without (3A) or with (3B) tissue loss Type 4 Right/Left hepatic duct or sectoral duct injuries without (4A) or with (4B) tissue loss Type 5 Bile duct injuries associated with vascular injuries
1 Insecure closure of cystic duct; too deep dissection into gallbladder bed 2 Incision of CBD instead of cystic duct for operative Cholangiogram; Clipping of CBD but recognized; Laceration of cystic duct/CBD junction; Diathermy injury to CBD/CHD 3 CBD mistaken as cystic duct, with CBD/CHD transected or Resected; Diathermy injury 4 Right HD or sectoral duct mistaken for cystic duct 5 Right hepatic artery mistaken for cystic artery; Diathermy or clip injuries to right hepatic artery
Only 25-33% of injures are recognized intraoperatively If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury) If not experienced, perform the cholangiogram laparoscopically with intent of referring patient (placement of drains) Consult an experienced hepatobiliary surgeon
DRAIN
REFRAIN
TRAIN
Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of the bile duct injury. Broad-spectrum antibiotics No need for an urgent laparotomy. Biliary reconstruction in the presence of peritonitis results a statistically worse outcome in patients. No need for urgent with reconstruction of the biliary tree. The inflammation, scar formation and development of fibrosis take several weeks to subside. Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.
Investigation
Ultrasonagraphy and CT (ductal dilatation and intra-abdominal collection) Cholangiogram
ERCPbiliary anatomy and assess the injury PTCdefine biliary anatomy proximal to injury MRCPnoninvasive (can miss minor leaks)
MR angiographyvascular injuries
Corrective Treatment
Endoscopic stenting for strictures T-tube placement for minor lacerations
Primary duct-to-duct repair only if tension free anastomosis available Biliary anastomosis with jejunal loop for major excisional injuries
Attention to operative details (insufficient close or deep plane) Stasbergs critical view of safety Appropriate Handling of Gallbladder Careful use of diathermy Recognition of Biliary and Vasculature Anomalies
LW Way, et al