Laparoscopic Bile Duct Injuries Risk Factors,
Recognition, and Repair
Ricardo L. Rossi, MD; William J. Schirmer, MD; John W.
patients undergoing biliary reconstruction laparoscopic cholecystectomy are reviewed. Ductal
\s=b\ Records
after
Braasch, MD;
triangle. Risk factors include scarring, acute cholecys-
titis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients
required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised. (Arch Surg. 1992;127:596-602) in the number
that the procedure. Early pub¬ demonstrated the safety lished reports1"1 suggest rates of injury to the common bile duct in the range of 0.2% to 3%; the risk of injury expected with the traditional open procedure is about 1 in 1000.M Some authors4 have suggested that the high rates of duc¬ tal injury are a product of the "learning curve." However, it is possible that the risks associated with laparoscopie surgery can be minimized by recognition of specific risk factors and careful selection of patients. We have experienced a dramatic increase in the num¬ ber of referrals to our institution for management of inju¬ ries to the bile duct. This report reviews our experience in an attempt to determine specific risk factors, forms of presentation, and results of management. for publication February 1, 1992. Department of General Surgery, Lahey Clinic Medical Center, Burlington, Mass. Dr Schirmer is now with the Department of Surgery, Ohio State University College of Medicine, Columbus. Presented at the 72nd Annual Meeting of the New England Surgical Society, Quebec City, September 29, 1991. Reprint requests to Department of General Surgery, Lahey Clinic
Accepted From the
Burlington,
Lawrence
Munson,
MD
During a recent 8-month period, 11 patients were referred to the Lahey Clinic Medical Center for treatment of injuries to the bile duct sustained during laparoscopie cholecystectomy. De¬ scriptions of the initial operative findings and methods of repair were obtained from review of the operative notes as well as from telephone conversations with the operating surgeon. The sub¬ sequent course of each of these patients was determined by re¬ view of hospital records, review of roentgenographic films, con¬ versations with referring physicians, and the patient's history. Follow-up, ranging from 4 to 11 months, has been obtained for all 11 patients. RESULTS The patient population consisted of eight women and three men ranging in age from 18 to 58 years (median age, 35 years). An obesity index was calculated for each patient as follows: Obesity Index Weight (kilograms)/(Height2) (square meters). Clinical obesity is defined as an obesity index greater than 30 kg/m2.9 With use of this index, five of the 11 patients qualified as clinically obese at the time of laparoscopie cholecystectomy. The electrocautery was employed for dissection during laparoscopie cholecystectomy in nine patients, and the laser was used in the remaining two patients. Cholangiography was obtained in only one patient, and the result was misinterpreted as normal. The intraopera¬ tive study demonstrated good flow of contrast from the cystic duct to the common duct and into the duodenum. However, no retrograde flow of the common hepatic or intrahepatic bile ducts was visualized. The patient was subsequently proved to have complete transection at the level of the common hepatic duct. In no patient was an identifiable anatomic variant clearly defined during the laparoscopie procedure. One operative note described what was interpreted as an "ac¬ cessory cystic duct that was clipped." In retrospect, this clip was probably placed on the transected right hepatic duct, which was the level of injury discovered during reexploration. Another note read "several small tubular structures were identified going into the gallbladder and were clipped." At exploration, we found a transected common hepatic duct with normal intrahepatic biliary =
of laparoscopie cholecys¬ explosion retectomies being performed preceded studies of
Medical Center, 41 Mall Rd,
Sanders, MD; J.
PATIENTS AND METHODS
of 11
injuries resulted from failure to define the anatomy of Cal-
ot's
Laura B.
MA 01805 (Dr Rossi).
anatomy.
Ten of the 11 operative notes described some difficulty with operative dissection. The principal difficulties were
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Table 1.—Patient Characteristics and Fibrosis
Patient No./
Age, y/
Indext
Sex
or
Scarring of Calot's Triangle
Obesity
Operative Highlights of Laparoscopie Cholecystectomy* Acute
Cholecystitis
Bleeding
1/26/F
32
2/24/F
35
3/27/F
32
+
4/41/F
21
+
5/54/M
25
+
6/35/F 7/47/F
29
8/44/M
27
+
+
+
9/18/F 10/32/F
28
+
+
+
34
+
11/58/M
29
+
Fat in the Porta Hepatis
Clip Applier Malfunction
+ +
39
*Plus sign indicates that the condition was present and was described in an operative note or in a conversation with the operating sur¬ geon; minus sign, the condition was not present or not applicable. tObesity index equals weight (kilograms) divided by height squared (square meters). An obesity index greater than 30 kg/m2 is defined as clinical obesity.
ascribed to chronic scarring or fibrosis in the region of Calot's triangle (n 7), the presence of acute inflamma¬ tion or cholecystitis or both (n 5), bleeding that obscured the field of dissection (n 3), excess fat in the porta hepatis (n 3), and a malfunctioning clip applier (n 1) (Table 1). Three patients had had previous abdominal surgery, but in each patient the procedures were lower abdominal or pelvic; in no instance were the secondary adhesions thought to have contributed to the difficulties during dis¬ section. One injury was clearly recognized with the use of the operating laparoscope, whereas two were not fully ap¬ preciated until the laparoscopie procedure was aborted and the operation was converted to open cholecystec¬ tomy. In both of these patients, conversion to the open operation occurred only after extensive laparoscopie dis¬ section in patients with both acute cholecystitis and evi¬ dence of chronic scarring of Calot's triangle. In a fourth patient, injury to the bile duct was suspected when examination of the resected gallbladder at the time of op¬ eration revealed "some extra somewhat firm tissue with clips adjacent to the cystic duct node." A scan after administration of hepatoiminodiacetic acid was obtained on the night of operation, and the result was consistent with complete high ductal obstruction. In the remaining seven patients, the postoperative symptoms that preceded a definitive diagnosis of ductal injury are summarized in Table 2. The time of hospital¬ ization after laparoscopie cholecystectomy tended to be longer in these patients than would be expected after an uncomplicated procedure (median, 5 days; range, 1 to 10 days). All seven patients eventually became jaundiced. However, before the onset of jaundice, the symptom complex was fairly characteristic and consisted of an¬ orexia, abdominal distention caused by ileus or ascites or both, and a general failure to thrive in six of the seven pa¬ tients. Most patients complained of pain and had positive peritoneal signs on physical examination (n 5). Most patients had intraperitoneal leakage of bile and bile peri¬ tonitis (n 6). In only one patient were the symptoms those of painless jaundice. That patient had a clip across =
=
=
=
=
=
=
hepatic duct without leakage of bile and be¬ clinically jaundiced within 24 hours. Results of endoscopie retrograde cholangiopancreatog¬ raphy led to a definitive diagnosis of ductal injury in all seven patients. Before performance of this procedure, two patients underwent computed tomography and three pa¬ tients underwent abdominal ultrasonography. All five of these studies revealed large amounts of free intraperitoneal fluid. Paracentesis in three of these patients returned the
common
came
bilious ascitic fluid. Four patients underwent primary repair of the ductal injury at the Lahey Clinic Medical Center, Burlington, Mass. Seven patients underwent exploration for repair at an outside institution before referral to the Lahey Clinic. The most typical operative finding during the initial exploration for repair was high transection of the common hepatic duct, with a resected segment of extrahepatic common bile duct often extending to the level of the duo¬ denum (n 8). Two patients had multiple lateral rents in the common duct, and the final patient had a clip placed across the common hepatic duct. In 10 of the 11 patients, the initial operative procedure was hepaticojejunostomy below the level of the hepatic bifurcation (Table 3). In the 11th patient, the surgeons were unable to locate ducts suitable for anastomosis and left multiple subhepatic drains and a transhepatic stent. Reasons for referral among the seven patients who first underwent exploration elsewhere were early postopera¬ tive anastomotic stricture (n 4), prolonged leakage of bile (n 2), and inability to locate ducts suitable for anas¬ tomosis (n= 1) (Table 3). Three of the patients with early postoperative anastomotic stricture were treated with percutaneous transhepatic balloon stricture dilation with placement of an indwelling transhepatic stent. The fourth patient who had undergone failed dilation elsewhere un¬ derwent reexploration, at which time double hepaticoje¬ junostomy above the bifurcation to the individual right and left hepatic ducts was performed. The patient whose first exploration was performed elsewhere and in whom no ducts suitable for anastomosis could be located re¬ quired triple hepaticojejunostomy for transected ducts =
=
=
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Table 2.—Symptom
Length of Hospital
Initial Patient No.
Stay, d
Complex in
Day Injury
Patients With
Unrecognized
Anorexia
Ileus
Ductal
Injuries*
Was
Recognized
Failure
After Operation
to Thrive
Pain
Ascites
Jaundice
7
+
+
+
+
6
+
+
+
+
+
11
+
+
+
+
+
10
+
+
+
+
+
+
3
+
+
+
+
+
+
7
+
+
+
+
6
*Plus
sign
indicates that the condition
was
present;
Table
minus
sign,
3.—Operative
the condition
was
not
present.
Procedures and Outcomes Treatment at
Treatment Before Referral
Procedures
Patient No.
+
Procedures
Outcome
Hepaticojejunostomy at
Uncomplicated, doing well
Intrahepatic hepaticojejunostomy
ARDS,* fungal septicemia, cholangitis, recovered,
Outcome
bifurcation
Exploration, transhepatic tube,
Bile fistula,
Extrahepatic hepaticojejunostomy
Bile fistula
sepsis
drains
7
8 9 10
Intrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Intrahepatic hepaticojejunostomy Nonoperative
doing well Resolved, doing well
ARDS,
fungal septicemia,
recovered, doing well
Uncomplicated, doing well Uncomplicated, doing well Doing well
Extrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Hepaticojejunostomy
Cholangitis, bile leakage, sepsis Cholangitis, bile leakage, stricture Cholangitis, sepsis,
Cholangitis, sepsis,
Percutaneous dilation of stricture, stent
Doing well
Hepaticojejunostomy
Stricture, failed
Intrahepatic hepaticojejunostomy
Cholangitis (transhepatic stent in place),
at bifurcation
11
Nonoperative management
Percutaneous drain
Lahey Clinic
at
bifurcation
*ARDS indicates adult respiratory distress
stricture
stricture
dilation
management Percutaneous dilation of stricture, stent Percutaneous dilation of stricture, stent
Cholangitis, stent changed, doing well Doing well
resolved
syndrome.
well into the hilum of the liver. In both patients who were referred with prolonged leakage of bile, the fistulas closed with nonoperative management. After discharge from the Lahey Clinic, three patients required readmission because of fever and chills, sug¬ gesting an episode of cholangitis. All three patients had transhepatic tubes in place; two were placed at operation during hepaticojejunostomy and one was placed after balloon dilation of an anastomotic stricture. The symp¬ toms resolved in one patient after the tube was removed, the only treatment required in the second patient was in¬ travenously administered antibiotic therapy, and the pa¬ tient with an anastomotic stricture underwent change of the stent under percutaneous guidance. The other eight patients were doing well at the time of this report, with short-term follow-up times ranging from 4 to 11 months. These 11 patients required an average of 3.4 hospital
admissions per patient (range, two to six admissions), with an average total hospital stay of 28.6 days (range, 16 to 55 days). In patients who were previously employed, days of lost work attributable to injury to the bile duct ranged from 90 to 217 days. Two individuals reported losing their jobs because of absence from work. Six patients reported that they had initiated litigation against the surgeons who performed laparoscopie cholecystec¬
tomy.
COMMENT
injury to the bile duct during open chole¬ is about 1 in 1000.M In laparoscopie cholecys¬
The risk of
cystectomy tectomy, in which the surgeon has considerably
more
freedom in terms of patient selection, rates of injury to the common bile duct are between 0.2% and 3%.XA Despite the fact that laparoscopie cholecystectomy is associated
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Gallbladder
Common
Hepatic Duct "
Common
f Hepatic
Gallbladder
Cystic
i WJL L i
Duct
Duct
Cystic
Duct
Common
Bile
Common Bile Duct
Duct
Duodenum
VJ/J, ,'
-5llU.£|i|
Recognition, and Repair
Ricardo L. Rossi, MD; William J. Schirmer, MD; John W.
patients undergoing biliary reconstruction laparoscopic cholecystectomy are reviewed. Ductal
\s=b\ Records
after
Braasch, MD;
triangle. Risk factors include scarring, acute cholecys-
titis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients
required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised. (Arch Surg. 1992;127:596-602) in the number
that the procedure. Early pub¬ demonstrated the safety lished reports1"1 suggest rates of injury to the common bile duct in the range of 0.2% to 3%; the risk of injury expected with the traditional open procedure is about 1 in 1000.M Some authors4 have suggested that the high rates of duc¬ tal injury are a product of the "learning curve." However, it is possible that the risks associated with laparoscopie surgery can be minimized by recognition of specific risk factors and careful selection of patients. We have experienced a dramatic increase in the num¬ ber of referrals to our institution for management of inju¬ ries to the bile duct. This report reviews our experience in an attempt to determine specific risk factors, forms of presentation, and results of management. for publication February 1, 1992. Department of General Surgery, Lahey Clinic Medical Center, Burlington, Mass. Dr Schirmer is now with the Department of Surgery, Ohio State University College of Medicine, Columbus. Presented at the 72nd Annual Meeting of the New England Surgical Society, Quebec City, September 29, 1991. Reprint requests to Department of General Surgery, Lahey Clinic
Accepted From the
Burlington,
Lawrence
Munson,
MD
During a recent 8-month period, 11 patients were referred to the Lahey Clinic Medical Center for treatment of injuries to the bile duct sustained during laparoscopie cholecystectomy. De¬ scriptions of the initial operative findings and methods of repair were obtained from review of the operative notes as well as from telephone conversations with the operating surgeon. The sub¬ sequent course of each of these patients was determined by re¬ view of hospital records, review of roentgenographic films, con¬ versations with referring physicians, and the patient's history. Follow-up, ranging from 4 to 11 months, has been obtained for all 11 patients. RESULTS The patient population consisted of eight women and three men ranging in age from 18 to 58 years (median age, 35 years). An obesity index was calculated for each patient as follows: Obesity Index Weight (kilograms)/(Height2) (square meters). Clinical obesity is defined as an obesity index greater than 30 kg/m2.9 With use of this index, five of the 11 patients qualified as clinically obese at the time of laparoscopie cholecystectomy. The electrocautery was employed for dissection during laparoscopie cholecystectomy in nine patients, and the laser was used in the remaining two patients. Cholangiography was obtained in only one patient, and the result was misinterpreted as normal. The intraopera¬ tive study demonstrated good flow of contrast from the cystic duct to the common duct and into the duodenum. However, no retrograde flow of the common hepatic or intrahepatic bile ducts was visualized. The patient was subsequently proved to have complete transection at the level of the common hepatic duct. In no patient was an identifiable anatomic variant clearly defined during the laparoscopie procedure. One operative note described what was interpreted as an "ac¬ cessory cystic duct that was clipped." In retrospect, this clip was probably placed on the transected right hepatic duct, which was the level of injury discovered during reexploration. Another note read "several small tubular structures were identified going into the gallbladder and were clipped." At exploration, we found a transected common hepatic duct with normal intrahepatic biliary =
of laparoscopie cholecys¬ explosion retectomies being performed preceded studies of
Medical Center, 41 Mall Rd,
Sanders, MD; J.
PATIENTS AND METHODS
of 11
injuries resulted from failure to define the anatomy of Cal-
ot's
Laura B.
MA 01805 (Dr Rossi).
anatomy.
Ten of the 11 operative notes described some difficulty with operative dissection. The principal difficulties were
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Table 1.—Patient Characteristics and Fibrosis
Patient No./
Age, y/
Indext
Sex
or
Scarring of Calot's Triangle
Obesity
Operative Highlights of Laparoscopie Cholecystectomy* Acute
Cholecystitis
Bleeding
1/26/F
32
2/24/F
35
3/27/F
32
+
4/41/F
21
+
5/54/M
25
+
6/35/F 7/47/F
29
8/44/M
27
+
+
+
9/18/F 10/32/F
28
+
+
+
34
+
11/58/M
29
+
Fat in the Porta Hepatis
Clip Applier Malfunction
+ +
39
*Plus sign indicates that the condition was present and was described in an operative note or in a conversation with the operating sur¬ geon; minus sign, the condition was not present or not applicable. tObesity index equals weight (kilograms) divided by height squared (square meters). An obesity index greater than 30 kg/m2 is defined as clinical obesity.
ascribed to chronic scarring or fibrosis in the region of Calot's triangle (n 7), the presence of acute inflamma¬ tion or cholecystitis or both (n 5), bleeding that obscured the field of dissection (n 3), excess fat in the porta hepatis (n 3), and a malfunctioning clip applier (n 1) (Table 1). Three patients had had previous abdominal surgery, but in each patient the procedures were lower abdominal or pelvic; in no instance were the secondary adhesions thought to have contributed to the difficulties during dis¬ section. One injury was clearly recognized with the use of the operating laparoscope, whereas two were not fully ap¬ preciated until the laparoscopie procedure was aborted and the operation was converted to open cholecystec¬ tomy. In both of these patients, conversion to the open operation occurred only after extensive laparoscopie dis¬ section in patients with both acute cholecystitis and evi¬ dence of chronic scarring of Calot's triangle. In a fourth patient, injury to the bile duct was suspected when examination of the resected gallbladder at the time of op¬ eration revealed "some extra somewhat firm tissue with clips adjacent to the cystic duct node." A scan after administration of hepatoiminodiacetic acid was obtained on the night of operation, and the result was consistent with complete high ductal obstruction. In the remaining seven patients, the postoperative symptoms that preceded a definitive diagnosis of ductal injury are summarized in Table 2. The time of hospital¬ ization after laparoscopie cholecystectomy tended to be longer in these patients than would be expected after an uncomplicated procedure (median, 5 days; range, 1 to 10 days). All seven patients eventually became jaundiced. However, before the onset of jaundice, the symptom complex was fairly characteristic and consisted of an¬ orexia, abdominal distention caused by ileus or ascites or both, and a general failure to thrive in six of the seven pa¬ tients. Most patients complained of pain and had positive peritoneal signs on physical examination (n 5). Most patients had intraperitoneal leakage of bile and bile peri¬ tonitis (n 6). In only one patient were the symptoms those of painless jaundice. That patient had a clip across =
=
=
=
=
=
=
hepatic duct without leakage of bile and be¬ clinically jaundiced within 24 hours. Results of endoscopie retrograde cholangiopancreatog¬ raphy led to a definitive diagnosis of ductal injury in all seven patients. Before performance of this procedure, two patients underwent computed tomography and three pa¬ tients underwent abdominal ultrasonography. All five of these studies revealed large amounts of free intraperitoneal fluid. Paracentesis in three of these patients returned the
common
came
bilious ascitic fluid. Four patients underwent primary repair of the ductal injury at the Lahey Clinic Medical Center, Burlington, Mass. Seven patients underwent exploration for repair at an outside institution before referral to the Lahey Clinic. The most typical operative finding during the initial exploration for repair was high transection of the common hepatic duct, with a resected segment of extrahepatic common bile duct often extending to the level of the duo¬ denum (n 8). Two patients had multiple lateral rents in the common duct, and the final patient had a clip placed across the common hepatic duct. In 10 of the 11 patients, the initial operative procedure was hepaticojejunostomy below the level of the hepatic bifurcation (Table 3). In the 11th patient, the surgeons were unable to locate ducts suitable for anastomosis and left multiple subhepatic drains and a transhepatic stent. Reasons for referral among the seven patients who first underwent exploration elsewhere were early postopera¬ tive anastomotic stricture (n 4), prolonged leakage of bile (n 2), and inability to locate ducts suitable for anas¬ tomosis (n= 1) (Table 3). Three of the patients with early postoperative anastomotic stricture were treated with percutaneous transhepatic balloon stricture dilation with placement of an indwelling transhepatic stent. The fourth patient who had undergone failed dilation elsewhere un¬ derwent reexploration, at which time double hepaticoje¬ junostomy above the bifurcation to the individual right and left hepatic ducts was performed. The patient whose first exploration was performed elsewhere and in whom no ducts suitable for anastomosis could be located re¬ quired triple hepaticojejunostomy for transected ducts =
=
=
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Table 2.—Symptom
Length of Hospital
Initial Patient No.
Stay, d
Complex in
Day Injury
Patients With
Unrecognized
Anorexia
Ileus
Ductal
Injuries*
Was
Recognized
Failure
After Operation
to Thrive
Pain
Ascites
Jaundice
7
+
+
+
+
6
+
+
+
+
+
11
+
+
+
+
+
10
+
+
+
+
+
+
3
+
+
+
+
+
+
7
+
+
+
+
6
*Plus
sign
indicates that the condition
was
present;
Table
minus
sign,
3.—Operative
the condition
was
not
present.
Procedures and Outcomes Treatment at
Treatment Before Referral
Procedures
Patient No.
+
Procedures
Outcome
Hepaticojejunostomy at
Uncomplicated, doing well
Intrahepatic hepaticojejunostomy
ARDS,* fungal septicemia, cholangitis, recovered,
Outcome
bifurcation
Exploration, transhepatic tube,
Bile fistula,
Extrahepatic hepaticojejunostomy
Bile fistula
sepsis
drains
7
8 9 10
Intrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Intrahepatic hepaticojejunostomy Nonoperative
doing well Resolved, doing well
ARDS,
fungal septicemia,
recovered, doing well
Uncomplicated, doing well Uncomplicated, doing well Doing well
Extrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Extrahepatic hepaticojejunostomy Hepaticojejunostomy
Cholangitis, bile leakage, sepsis Cholangitis, bile leakage, stricture Cholangitis, sepsis,
Cholangitis, sepsis,
Percutaneous dilation of stricture, stent
Doing well
Hepaticojejunostomy
Stricture, failed
Intrahepatic hepaticojejunostomy
Cholangitis (transhepatic stent in place),
at bifurcation
11
Nonoperative management
Percutaneous drain
Lahey Clinic
at
bifurcation
*ARDS indicates adult respiratory distress
stricture
stricture
dilation
management Percutaneous dilation of stricture, stent Percutaneous dilation of stricture, stent
Cholangitis, stent changed, doing well Doing well
resolved
syndrome.
well into the hilum of the liver. In both patients who were referred with prolonged leakage of bile, the fistulas closed with nonoperative management. After discharge from the Lahey Clinic, three patients required readmission because of fever and chills, sug¬ gesting an episode of cholangitis. All three patients had transhepatic tubes in place; two were placed at operation during hepaticojejunostomy and one was placed after balloon dilation of an anastomotic stricture. The symp¬ toms resolved in one patient after the tube was removed, the only treatment required in the second patient was in¬ travenously administered antibiotic therapy, and the pa¬ tient with an anastomotic stricture underwent change of the stent under percutaneous guidance. The other eight patients were doing well at the time of this report, with short-term follow-up times ranging from 4 to 11 months. These 11 patients required an average of 3.4 hospital
admissions per patient (range, two to six admissions), with an average total hospital stay of 28.6 days (range, 16 to 55 days). In patients who were previously employed, days of lost work attributable to injury to the bile duct ranged from 90 to 217 days. Two individuals reported losing their jobs because of absence from work. Six patients reported that they had initiated litigation against the surgeons who performed laparoscopie cholecystec¬
tomy.
COMMENT
injury to the bile duct during open chole¬ is about 1 in 1000.M In laparoscopie cholecys¬
The risk of
cystectomy tectomy, in which the surgeon has considerably
more
freedom in terms of patient selection, rates of injury to the common bile duct are between 0.2% and 3%.XA Despite the fact that laparoscopie cholecystectomy is associated
Downloaded From: http://archsurg.jamanetwork.com/ by a Thomas Jefferson University User on 05/13/2015
Gallbladder
Common
Hepatic Duct "
Common
f Hepatic
Gallbladder
Cystic
i WJL L i
Duct
Duct
Cystic
Duct
Common
Bile
Common Bile Duct
Duct
Duodenum
VJ/J, ,'
-5llU.£|i|
