Management of Biliary Tract Injury during Laparoscopic Cholecystectomy
Ahmed Mohammed OudaElshemy;
Abstract
Bile duct injuries will be always the worst complication of cholecystectomy. Though they will always takeplace, the incidence and severity can be reduced. Knowledge of how and why they occur can go a long way towardpreventing debilitating and life threatening sequelae.
The incidence of bile duct injury seems to be marginally higher after laparoscopic cholecystectomy than afteropen surgery. Iatrogenic bile duct injuries continue to occur despite increasing experience with laparoscopiccholecystectomy. Careful surgical technique, early recognition, and appropriate management at a specializedhepatobiliary center should decrease the frequency and minimize the morbidity associated with these injuries.
The best treatment for injury of the biliary tract is prevention by adequate education ofsurgeons in the performance of a safe technique of cholecystectomy.
It is very important for every surgeon to be aware of the variants ofbiliary duct anatomy. It is recommended that, the routine use of intra-operative cholangiography in association with careful dissection of the blood supply to avoid any unexpected bleeding is essential. Injuries recognized during theoperation must be repaired immediately by a specific technique suited to the specific injury.
On the other hand,injuries recognized in the early postoperative period do not require immediate repair except in the case of biliaryperitonitis.
A delayed elective reconstruction is associated with fewer complications compared to acute repair undersuboptimal circumstances and has a success rate of 90% in experienced centers. Diagnostic work up andtreatment of bile duct injuries needs a multidisciplinary approach (gastroenterologists, radiologists, surgeons).Surgical reconstruction for delayed detected bile duct injuries in the early postoperative phase is associatedwith a higher risk for complication compared with elective repair after 6-8 weeks.
Precise operative correction is necessary for successful repair of bile duct injuries. The first step in itsmanagement is to define the proximal bile duct anatomy, relieve obstruction, and control biliary leak. Surgicalreconstruction with Roux-en-Y hepaticojejunostomy with mucosa to mucosa repair seems to be the best way torestore bile flow to the digestive tract.
Once identified, operative repair by hepaticojejunostomy, mucosa-to-mucosa, should be successful in nearly90% of patients. The first repair of the injury has the best chance of success. Successful repair requires the abilityto dissect above the injury to normal bile duct, and perform high hepaticojejunostomies if necessary to individualducts. End-to-end repair has a high percentage of failure and it is better to be avoided whenever possible.
Non-operative management of postoperative bile duct stricturesby percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in some patients.
The incidence of bile duct injury seems to be marginally higher after laparoscopic cholecystectomy than afteropen surgery. Iatrogenic bile duct injuries continue to occur despite increasing experience with laparoscopiccholecystectomy. Careful surgical technique, early recognition, and appropriate management at a specializedhepatobiliary center should decrease the frequency and minimize the morbidity associated with these injuries.
The best treatment for injury of the biliary tract is prevention by adequate education ofsurgeons in the performance of a safe technique of cholecystectomy.
It is very important for every surgeon to be aware of the variants ofbiliary duct anatomy. It is recommended that, the routine use of intra-operative cholangiography in association with careful dissection of the blood supply to avoid any unexpected bleeding is essential. Injuries recognized during theoperation must be repaired immediately by a specific technique suited to the specific injury.
On the other hand,injuries recognized in the early postoperative period do not require immediate repair except in the case of biliaryperitonitis.
A delayed elective reconstruction is associated with fewer complications compared to acute repair undersuboptimal circumstances and has a success rate of 90% in experienced centers. Diagnostic work up andtreatment of bile duct injuries needs a multidisciplinary approach (gastroenterologists, radiologists, surgeons).Surgical reconstruction for delayed detected bile duct injuries in the early postoperative phase is associatedwith a higher risk for complication compared with elective repair after 6-8 weeks.
Precise operative correction is necessary for successful repair of bile duct injuries. The first step in itsmanagement is to define the proximal bile duct anatomy, relieve obstruction, and control biliary leak. Surgicalreconstruction with Roux-en-Y hepaticojejunostomy with mucosa to mucosa repair seems to be the best way torestore bile flow to the digestive tract.
Once identified, operative repair by hepaticojejunostomy, mucosa-to-mucosa, should be successful in nearly90% of patients. The first repair of the injury has the best chance of success. Successful repair requires the abilityto dissect above the injury to normal bile duct, and perform high hepaticojejunostomies if necessary to individualducts. End-to-end repair has a high percentage of failure and it is better to be avoided whenever possible.
Non-operative management of postoperative bile duct stricturesby percutaneous transhepatic or endoscopic balloon dilatation has been reported to be successful in some patients.
Other data
| Title | Management of Biliary Tract Injury during Laparoscopic Cholecystectomy | Other Titles | تشخيص وعلاج إصابة القنوات المرارية أثناء استئصال الحويصلة المرارية باستخدام المنظار الجراحي | Authors | Ahmed Mohammed OudaElshemy | Issue Date | 2015 |
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