Case report Br. J. Surg. 1992, Vol. 79, March, 231-232
Bile duct injury following la pa roscopic c holecystectomy S. Cheslyn-Curtis, M. Emberton, H. Ahmed, R . C. N. Williamson and N. A. Habib Hepatopancreatobiliary Unit, Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK Correspondence to: Miss S . Cheslyn-Curtis, 61 Burntwood Grange Road, London SW18 3JY, UK
Laparoscopic cholecystectomy has been introduced without the caution normally accorded to a new technique and without a controlled study comparing it to the conventional operation. The overall safety of the procedure appears to be similar to that of conventional cholecystectomy but bile duct injury may be more common','. Two cases are reported to emphasize the importance of this complication and to stress the need for careful surveillance of the safety of the procedure.
Case reports
Figure 1 Percutaneous transhepatic cholangiogram showing a dilated intrahepatic biliary system with obstruction at the liver hilum just below the biliary convergence. Note the presence of titanium clips just below that level
Patient 1 A 59-year-old woman was referred with a biliary stricture which developed 3 months after laparoscopic cholecystectomy. At the original operation, the cystic duct was noted to be short and it was thought to insert directly into the right hepatic duct. It was dissected and titanium clips were applied. After operation the patient developed a biliary fistula which closed spontaneously after 2 weeks. Three months later she presented with right hypochondria1 pain and obstructive jaundice. A percutaneous transhepatic cholangiogram showed obstruction of the common hepatic duct and thereafter the patient became deeply jaundiced and febrile. Liver function tests showed a bilirubin level of 234 pmol/l, alkaline phosphatase of 1320 units/l and aspartate transaminase of 31 units/l. A second percutaneous transhepatic cholangiogram showed a tight stricture immediately below the origin of the common hepatic duct (Figure 1 ) and a biliary leak from the previous cholangiography puncture site. Coeliac axis angiography excluded any hepatic vascular injury. At laparotomy, the peritoneal cavity contained 2 litres of bile. There were extensive adhesions, especially to the gallbladder bed. The stricture was identified just below the level of the biliary convergence and appeared to be related to a titanium clip. This Bismuth type 111 stricture was excised and a hepaticojejunostomy Roux-en-Y performed. The patient recovered uneventfully and was discharged 1 week later. A postoperative 99"Tc-EHIDA (iminodiacetic acid derivative) scan showed good biliary excretion with no anastomotic narrowing or leakage. Patient 2 A 33-year-old woman was referred for assessment and management of a persistent subphrenic bile collection 3 weeks after laparoscopic cholecystectomy. There had been difficulty in identifying the ductal anatomy and two ductal structures were divided which seemed to communicate with the gallbladder. The patient developed persistent right upper quadrant pain and ultrasonography showed a subhepatic bile collection which was drained and a biliary tree of normal calibre. Endoscopic retrograde cholangiopancreatography demonstrated a normal common bile duct and left hepatic ductal system. There was extravasation of contrast close to the clipped cystic duct which filled a large cavity and eventually opacified the right ductal system. The patient was referred with established sepsis. Results of liver function tests were normal apart from a raised alkaline phosphatase level (489 units/l). Coeliac axis angiography excluded any vascular injury. At laparotomy the proximal injured end of the right hepatic duct was draining freely into a large subhepatic
ooO7-1323/92/030231-02
C 1992 Butterworth-Heinemann Ltd
Figure 2 Intraoperative cholangiogram showing the right and k f i hepatic ductal systems. The right hepatic duct was cannuluted through its open end and the left ductal system was shown by injecting contrast via the cystic duct after removal of its titanium clip cavity. Intraoperative cholangiography (Figure 2 ) confirmed an injured right hepatic with a normal left ductal system. A right hepaticojejunostomy Roux-en-Y was performed. The postoperative course was complicated by a wound infection and psychotic depression.
231
Case report
Discussion There is minimal morbidity following conventional cholecystectomy, and bile duct injuries occur in 0.1-0.4 per cent of cases3q4. The incidence of bile duct injury following laparoscopic cholecystectomy may be higher. Despite the advantages of the technique, its use may not be justified if it proves to be less safe than the conventional operation. The cases reported illustrate two important points. Not all bile duct injuries are apparent at the time of cholecystectomy or in the immediate postoperative period. The first patient presented with jaundice 3 months after the operation. The biliary fistula was assumed to be due to drainage from an accessory duct or the cystic duct and resolved spontaneously. In fact, a titanium clip was partly occluding the common hepatic duct which with stricturing due to the trauma led to complete obstruction. In both patients there was difficulty in identifying the bile duct anatomy which the surgeon thought to be anomalous. In the first patient, the duct may have been caught while clipping another structure, but in the second the right hepatic duct appears to have been mistaken for the cystic duct which was identified later in the operation. Peroperative cholangiography has been abandoned by most surgeons who perform laparoscopic cholecystectomy because of technical difficulty and the extra time taken. Cholangiography is useful for determining the ductal anatomy and may have prevented injury. If cholangiography is not performed then conversion to open operation should occur when there is uncertainty in identification of ductal anatomy. Angiography was performed in both patients before re-exploration because associated vascular injuries can cause bile duct ischaemia, affecting anastomotic healing and future stricturing. In a series of 78
232
patients with postcholecystectomy bile duct strictures, 19 of 25 patients undergoing angiography because of a history of operative vascular injury showed evidence of arterial or portal injury5. In these patients, the anastomosis is best performed at the liver hilum even if there is normal duct below. It is probably no longer feasible to perform a controlled trial comparing new and old techniques of cholecystectomy6. The morbidity of the procedure, particularly from bile duct injury, needs to be accurately audited on a national scale to assess the incidence, reasons for injury and how the complication can be avoided.
References 1.
2. 3. 4. 5.
6.
Peters JH, Ellison EC, Innes JT et al. Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 1991; 213: 3-12. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopiccholecystectomies. NEnglJMed 1991 ;324:1073-8. Raute M,Schaupp W. Iatrogenic damage of the bile ducts caused by cholecystectomy. Langenbecks Arch Chir 1988; 373: 345-54. Habib NA, Foo CF, Cox S et af. Complications of cholecystectomy in district general hospitals. Br J CIin Pract 1990; 66: 189-92. Blumgart LH. Biliary stricture and fistula. In: Blumgart LH, ed. Surgery of the Liver and Biliary Tract. London: Churchill Livingstone, 1988: 721-52. Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R and the Cholecystectomy Study Group. Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Br J Surg 1991; 78: 150-4.
Paper accepted 6 November 1991
Br. J. Surg.. Vol. 79, No. 3, March 1992
Bile duct injury following la pa roscopic c holecystectomy S. Cheslyn-Curtis, M. Emberton, H. Ahmed, R . C. N. Williamson and N. A. Habib Hepatopancreatobiliary Unit, Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK Correspondence to: Miss S . Cheslyn-Curtis, 61 Burntwood Grange Road, London SW18 3JY, UK
Laparoscopic cholecystectomy has been introduced without the caution normally accorded to a new technique and without a controlled study comparing it to the conventional operation. The overall safety of the procedure appears to be similar to that of conventional cholecystectomy but bile duct injury may be more common','. Two cases are reported to emphasize the importance of this complication and to stress the need for careful surveillance of the safety of the procedure.
Case reports
Figure 1 Percutaneous transhepatic cholangiogram showing a dilated intrahepatic biliary system with obstruction at the liver hilum just below the biliary convergence. Note the presence of titanium clips just below that level
Patient 1 A 59-year-old woman was referred with a biliary stricture which developed 3 months after laparoscopic cholecystectomy. At the original operation, the cystic duct was noted to be short and it was thought to insert directly into the right hepatic duct. It was dissected and titanium clips were applied. After operation the patient developed a biliary fistula which closed spontaneously after 2 weeks. Three months later she presented with right hypochondria1 pain and obstructive jaundice. A percutaneous transhepatic cholangiogram showed obstruction of the common hepatic duct and thereafter the patient became deeply jaundiced and febrile. Liver function tests showed a bilirubin level of 234 pmol/l, alkaline phosphatase of 1320 units/l and aspartate transaminase of 31 units/l. A second percutaneous transhepatic cholangiogram showed a tight stricture immediately below the origin of the common hepatic duct (Figure 1 ) and a biliary leak from the previous cholangiography puncture site. Coeliac axis angiography excluded any hepatic vascular injury. At laparotomy, the peritoneal cavity contained 2 litres of bile. There were extensive adhesions, especially to the gallbladder bed. The stricture was identified just below the level of the biliary convergence and appeared to be related to a titanium clip. This Bismuth type 111 stricture was excised and a hepaticojejunostomy Roux-en-Y performed. The patient recovered uneventfully and was discharged 1 week later. A postoperative 99"Tc-EHIDA (iminodiacetic acid derivative) scan showed good biliary excretion with no anastomotic narrowing or leakage. Patient 2 A 33-year-old woman was referred for assessment and management of a persistent subphrenic bile collection 3 weeks after laparoscopic cholecystectomy. There had been difficulty in identifying the ductal anatomy and two ductal structures were divided which seemed to communicate with the gallbladder. The patient developed persistent right upper quadrant pain and ultrasonography showed a subhepatic bile collection which was drained and a biliary tree of normal calibre. Endoscopic retrograde cholangiopancreatography demonstrated a normal common bile duct and left hepatic ductal system. There was extravasation of contrast close to the clipped cystic duct which filled a large cavity and eventually opacified the right ductal system. The patient was referred with established sepsis. Results of liver function tests were normal apart from a raised alkaline phosphatase level (489 units/l). Coeliac axis angiography excluded any vascular injury. At laparotomy the proximal injured end of the right hepatic duct was draining freely into a large subhepatic
ooO7-1323/92/030231-02
C 1992 Butterworth-Heinemann Ltd
Figure 2 Intraoperative cholangiogram showing the right and k f i hepatic ductal systems. The right hepatic duct was cannuluted through its open end and the left ductal system was shown by injecting contrast via the cystic duct after removal of its titanium clip cavity. Intraoperative cholangiography (Figure 2 ) confirmed an injured right hepatic with a normal left ductal system. A right hepaticojejunostomy Roux-en-Y was performed. The postoperative course was complicated by a wound infection and psychotic depression.
231
Case report
Discussion There is minimal morbidity following conventional cholecystectomy, and bile duct injuries occur in 0.1-0.4 per cent of cases3q4. The incidence of bile duct injury following laparoscopic cholecystectomy may be higher. Despite the advantages of the technique, its use may not be justified if it proves to be less safe than the conventional operation. The cases reported illustrate two important points. Not all bile duct injuries are apparent at the time of cholecystectomy or in the immediate postoperative period. The first patient presented with jaundice 3 months after the operation. The biliary fistula was assumed to be due to drainage from an accessory duct or the cystic duct and resolved spontaneously. In fact, a titanium clip was partly occluding the common hepatic duct which with stricturing due to the trauma led to complete obstruction. In both patients there was difficulty in identifying the bile duct anatomy which the surgeon thought to be anomalous. In the first patient, the duct may have been caught while clipping another structure, but in the second the right hepatic duct appears to have been mistaken for the cystic duct which was identified later in the operation. Peroperative cholangiography has been abandoned by most surgeons who perform laparoscopic cholecystectomy because of technical difficulty and the extra time taken. Cholangiography is useful for determining the ductal anatomy and may have prevented injury. If cholangiography is not performed then conversion to open operation should occur when there is uncertainty in identification of ductal anatomy. Angiography was performed in both patients before re-exploration because associated vascular injuries can cause bile duct ischaemia, affecting anastomotic healing and future stricturing. In a series of 78
232
patients with postcholecystectomy bile duct strictures, 19 of 25 patients undergoing angiography because of a history of operative vascular injury showed evidence of arterial or portal injury5. In these patients, the anastomosis is best performed at the liver hilum even if there is normal duct below. It is probably no longer feasible to perform a controlled trial comparing new and old techniques of cholecystectomy6. The morbidity of the procedure, particularly from bile duct injury, needs to be accurately audited on a national scale to assess the incidence, reasons for injury and how the complication can be avoided.
References 1.
2. 3. 4. 5.
6.
Peters JH, Ellison EC, Innes JT et al. Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 1991; 213: 3-12. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopiccholecystectomies. NEnglJMed 1991 ;324:1073-8. Raute M,Schaupp W. Iatrogenic damage of the bile ducts caused by cholecystectomy. Langenbecks Arch Chir 1988; 373: 345-54. Habib NA, Foo CF, Cox S et af. Complications of cholecystectomy in district general hospitals. Br J CIin Pract 1990; 66: 189-92. Blumgart LH. Biliary stricture and fistula. In: Blumgart LH, ed. Surgery of the Liver and Biliary Tract. London: Churchill Livingstone, 1988: 721-52. Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Lefering R and the Cholecystectomy Study Group. Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Br J Surg 1991; 78: 150-4.
Paper accepted 6 November 1991
Br. J. Surg.. Vol. 79, No. 3, March 1992
