Management of Post-cholecystectomy Iatrogenic Bile Duct Injuries

Abstract

Knowledge of anatomic variation is important in the operative setting. When the usual appearance of structures is not encountered, it can be tempting to fit abnormal findings within the paradigm of what is normal. This practice can lead to errors and injury. Intraoperative cholangiography can be helpful in interpreting the anatomy and should be used liberally Laparoscopic cholecystectomy has largely replaced open cholecystectomy because of shorter hospital stay, faster recovery, and lower overall morbidity. Unfortunately, however, the morbidity due to bile duct injury has increased with the advent of the laparoscopic approach Visualization of this “critical view” is important in preventing injury to the bile ducts. At this point two structures (cystic artery and cystic duct) should be seen entering the gallbladder. The key to early recognition is to suspect a problem in any patient who fails to do well following laparoscopic cholecystectomy. Because these patients usually do extremely well, any deviation from this should be recognized as a problem. Treatment of IBDI is complex and multidisciplinary. The following factors need to be known: the type of injury, the patient’s clinical condition, associated vascular damage, local hospital factors, etc. Endoscopic management is relatively simple, reversible, and minimally invasive. Thus, endoscopic management should be an integral part of the therapeutic algorithm in the majority of patients with significant biliary tract injuries. However, the success of endoscopic therapy depends upon the type of injury. An attempt at endoscopic therapy does not preclude subsequent surgical intervention and endoscopic stenting should be seen as a possible definitive therapy and at the very least a bridge to surgery. A multidisciplinary approach between biliary endoscopist, surgeon and radiologist is required for managing these patients Mismanagement can result in lifelong disability and chronic liver disease. Given the unforgiving nature of the biliary tree, favorable outcome requires a well-thought-out strategy and attention to details