Case reports continued Common bile duct injury after laparoscopic cholecystectomy: Report of two cases JOY Y. SELIGMAN, DO JERRY J. RAGLAND, MD With a few exceptions, laparoscopic cholecystectomy has rapidly supplanted open cholecystectomy as the operation of choice for symptomatic cholelithiasis. The risk of bile duct injury using the laparoscopic technique is almost twice that of the open technique (0% to 1% vs 0% to 0.5%). There appears to be a direct correlation between the number of cases an individual surgeon performs and the frequency of bile duct injury. The nature of bile duct injuries following the laparoscopic technique tends to be more serious than those seen following the open prodecure. In addition, more than 50% of bile duct injuries go unde- tected at the time of operation. A number of technical steps can be taken to help prevent bile duct injuries when using the laparoscopic technique. This article reports two such cases to alert the surgeon that a high index of suspicion must always be maintained concerning the possibility of bile duct injury following laparoscopic cholecystectomy. (Key words: Laparoscopic cholecystectomy, bile duct, high index of sus- picion) 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, pp 539- 545,550. 3. Hudson JI, Pope HG, Jonas IM: Psychosis in anorex- ia nervosa and bulimia. Br J Psychiatry 1984;145:420- 423. 4. Grounds A: Transient psychoses in anorexia ner- vosa. Psychol Med 1982;12:107-113. 5. Lacey JH, Crisp AH: Hunter, food intake and weight: The impact of clomipramine on a refeeding anorexia nervosa population. Postgrad Med J1980;1:(56 suppl) 79-85. 6. Crisp AH, Lacey JH, Crutchfield M: Clomipramine and "drive" in people with anorexia nervosa: An in- patient study. Br J Psychiatry 1987;150:355-358. 7. Kennedy SH, Garfinkel PH: Advances in diagnosis and treatment of anorexia nervosa and bulimia nervosa. Can J Psychiatry 1992;37:309-315. L aparoscopic cholecystectomy was introduced in the United States by Reddick and colleagues in 1988.1 The procedure quickly became the preferred therapeutic option for symptomatic cholelithiasis.1 The rapidity with which laparoscopic cholecystectomy replaced open cholecystectomy precluded clini- cians from being fully aware of the com- plications that may be associated with this laparoscopic procedure. We present two patient studies to alert clinicians to the potential subtleties of common duct injuries with bile leaks that can be a result From the Departments of General Surgery and Clin- ical Investigation, Naval Medical Center, San Diego, California. The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program sponsored this report #84-16-1968-506, as required by HSETCINST 6000.41A. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Depart- ment of the Navy, Department of Defense, or the United States Government. Correspondence to LCDR J.Y. Seligman, MC, USNR, do Clinical Investigation Department Naval Medical Center, San Diego, CA 92134-5000. of the performance of laparoscopic chole- cystectomy. Report of cases Case I A 33-year-old woman was referred for elective laparoscopic cholecystectomy for documented symptomatic cholelithiasis. Physical examination, screening labora- tory data including liver function studies, and chest x-ray films were all normal. The operative procedure was described as technically difficult because of scarring, and the total operative time exceeded 3 hours. Intraoperative cholangiography was not performed. The patient was discharged on post- operative day 2 but was readmitted on day 7 with symptoms of constipation, anorexia, low- grade fever, and crampy abdominal pain. White blood cell (WBC) count was 9500/mm3 with a minimal left shift. Bilirubin, alkaline phosphatase, and other liver function studies were all normal. Plain radiograph films revealed Wenokur and Luby • Case reports/Seligman and Ragland • Case reports JAOA • Vol 97 • No 4 • April 1997 • 233
Transcript
Case reports continued
Common bile duct injury after laparoscopiccholecystectomy: Report of two cases
JOY Y. SELIGMAN, DOJERRY J. RAGLAND, MD
With a few exceptions, laparoscopic cholecystectomy has rapidly supplantedopen cholecystectomy as the operation of choice for symptomatic cholelithiasis.The risk of bile duct injury using the laparoscopic technique is almost twicethat of the open technique (0% to 1% vs 0% to 0.5%). There appears to be adirect correlation between the number of cases an individual surgeon performsand the frequency of bile duct injury. The nature of bile duct injuries followingthe laparoscopic technique tends to be more serious than those seen followingthe open prodecure. In addition, more than 50% of bile duct injuries go unde-tected at the time of operation. A number of technical steps can be taken to helpprevent bile duct injuries when using the laparoscopic technique. This articlereports two such cases to alert the surgeon that a high index of suspicion mustalways be maintained concerning the possibility of bile duct injury followinglaparoscopic cholecystectomy.
(Key words: Laparoscopic cholecystectomy, bile duct, high index of sus-picion)
2. American Psychiatric Association: Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition.Washington, DC, American Psychiatric Association,1994, pp 539- 545,550.
3. Hudson JI, Pope HG, Jonas IM: Psychosis in anorex-ia nervosa and bulimia. Br J Psychiatry 1984;145:420-423.
4. Grounds A: Transient psychoses in anorexia ner-vosa. Psychol Med 1982;12:107-113.
5. Lacey JH, Crisp AH: Hunter, food intake and weight:The impact of clomipramine on a refeeding anorexianervosa population. Postgrad Med J1980;1:(56 suppl)79-85.
6. Crisp AH, Lacey JH, Crutchfield M: Clomipramineand "drive" in people with anorexia nervosa: An in-patient study. Br J Psychiatry 1987;150:355-358.
7. Kennedy SH, Garfinkel PH: Advances in diagnosisand treatment of anorexia nervosa and bulimia nervosa.Can J Psychiatry 1992;37:309-315.
Laparoscopic cholecystectomy wasintroduced in the United States by
Reddick and colleagues in 1988.1 Theprocedure quickly became the preferredtherapeutic option for symptomaticcholelithiasis.1 The rapidity with whichlaparoscopic cholecystectomy replacedopen cholecystectomy precluded clini-cians from being fully aware of the com-plications that may be associated withthis laparoscopic procedure. We presenttwo patient studies to alert clinicians tothe potential subtleties of common ductinjuries with bile leaks that can be a result
From the Departments of General Surgery and Clin-ical Investigation, Naval Medical Center, San Diego,California.
The Chief, Bureau of Medicine and Surgery, NavyDepartment, Washington, DC, Clinical InvestigationProgram sponsored this report #84-16-1968-506, asrequired by HSETCINST 6000.41A. The viewsexpressed in this article are those of the authors anddo not reflect the official policy or position of the Depart-ment of the Navy, Department of Defense, or theUnited States Government.
Correspondence to LCDR J.Y. Seligman, MC,USNR, do Clinical Investigation Department NavalMedical Center, San Diego, CA 92134-5000.
of the performance of laparoscopic chole-cystectomy.
Report of casesCase IA 33-year-old woman was referred forelective laparoscopic cholecystectomy fordocumented symptomatic cholelithiasis.Physical examination, screening labora-tory data including liver function studies,and chest x-ray films were all normal.The operative procedure was described astechnically difficult because of scarring,and the total operative time exceeded 3hours. Intraoperative cholangiographywas not performed.
The patient was discharged on post-operative day 2 but was readmitted onday 7 with symptoms of constipation,anorexia, low- grade fever, and crampyabdominal pain. White blood cell (WBC)count was 9500/mm3 with a minimalleft shift. Bilirubin, alkaline phosphatase,and other liver function studies were allnormal. Plain radiograph films revealed
Wenokur and Luby • Case reports/Seligman and Ragland • Case reports JAOA • Vol 97 • No 4 • April 1997 • 233
only a large amount of stool in her colon.Enemas were administered with symp-tomatic improvement, and the patientwas discharged from the hospital onlyto be readmitted on day 12 with recur-rence of her prior symptoms. Physicalexamination at this time was normalexcept for mild distension of theabdomen and minimal generalized ten-derness. Laboratory data remainedunchanged except for a total bilirubin of2.2 mg/dL. Plain radiograph films of theabdomen suggested fluid accumulationin the right-upper quadrant. Ultra-sonography confirmed fluid accumula-tion over and under the liver. A pelviccollection was noted also. This fluidaccumulation was at first thought torepresent hematoma, but when thepatient failed to improve, a culdocente-sis was performed that revealed a largeamount of bilious fluid. On day 20, thepatient underwent open exploration. Alateral injury to the common bile ductwas identified, and it was treated suc-cessfully with a "T" tube.
Case 2A 25-year-old woman was referred forelective laparoscopic cholecystectomy forsymptomatic cholelithiasis. Her opera-tion was difficult because of tightlypacked stones within the gallbladder andrelated difficulty in maintaining traction.Total operative time was just over 2hours. Intraoperative cholangiography(IOC) was not performed. The immedi-ate postoperative course was uncompli-cated, and the patient was dischargedhome on postoperative day 1. She wasreadmitted on postoperative day 5 withabdominal pain, nausea, and low-gradefever. Physical examination revealed onlyminimal, diffuse abdominal tenderness.The WBC was 13,000/mm 3, and liverfunction studies were all normal.Abdominal radiograph films revealedfree intraperitoneal air consistent withrecent operation and other nonspecificbowel gas pattern. Computed tomogra-phy (CT) scan revealed a fluid collec-tion over the liver and in the pelvis. Thefluid collection over the liver was inter-preted as a subcapsular hematoma. After5 days of inpatient observation, she was
the hecklistq Use 30-degree-angle
laparoscope for moreperpendicular view ofhepatoduodenal ligamentstructures.
q Use firm cephalad retractionon fundus of gallbladder tohelp expose hepatoduodenalligament structures and fullyopen Calot's triangle.
1=1 Use fully trained surgeon asfirst assistant whose primaryresponsibilities are monitoringtotal operation and providingretraction of infundibulum ofgallbladder laterally (notparallel) to common bile ductto help increase separation ofcystic and common bile ducts.
q Begin dissection of cystic ductnear infundibulum ofgallbladder; dissect in directionof common bile duct.
q Convert to opencholecystectomy whenbleeding more than minor orwhen dissection unusuallydifficult.
1=1 Use cautery device combinedwith suction/irrigation system.
q Use electrocautery withextreme care.
Adapted from Hunter JG: Avoidance of bileduct injury during laparoscopiccholecystec-tomy. Am J Surg 1991;161:71; and the au-thors' own experience.
Figure. Methods to prevent surgical commonbile duct injury.
discharged. Throughout the hospitaliza-tion, her liver function studies and WBCcount remained normal. She remainedafebrile as well. On postoperative day25, she was admitted a second time withdiffuse abdominal pain, nausea, emesis,and increasing abdominal distension. Onphysical examination the abdomen wasobviously distended with shifting dull-
ness and diffuse tenderness. Laboratorydata included: WBC, 7000/mm3; hema-tocrit, 31%; total bilirubin, 2.3 mg/dL;alkaline phosphatase, 678 U/L; andlipase, 896 U/L. A large quantity of bile-stained fluid was aspirated during cul-docentesis. An endoscopic retrogradecholangiopancreatography (ERCP) wasperformed, which revealed a normal dis-tal common bile duct with only a wisp ofdye going into the proximal hepatic rad-icals. During celiotomy, a 2-cm segmentof common hepatic duct was disinte-grated and fibrotic. A tube hepaticosto-my was performed, with reconstruction2 months later consisting of a Roux-en-Y hepaticojejunostomy.
DiscussionLaparoscopic techniques present a lessinvasive method of accomplishing chole-cystectomy. However, the risks for injuryto the extrahepatic biliary system remainthe same or may be even greater, sec-ondary to the inability to palpate thestructures in the hepaticoduodenal liga-ment. It has been noted by others2 thatthe nature of bile duct injuries followinglaparoscopic cholecystectomy tends tobe more serious than those seen follow-ing open cholecystectomy. Frequently,the bile duct has a portion resected, theproximal injury is high, and the ductdiameter is small.
Our two cases are similar because ofthe long delay between common ductinjury with bile leakage and the diag-nosis of injury. The symptoms, clinicalsigns, and radiographic data were sub-tle and confusing to the clinicians. Incase 1, an ERCP could have been per-formed and might have allowed stentplacement and internal drainage, avoid-ing the need for operative repair. In case2, an IOC might have been beneficialfor definition of the ductal anatomy.Even with normal liver function stud-ies/amylase done preoperatively, the pres-ence of multiple stones may have been anindication for IOC. In both cases, a cul-docentesis was performed.
Injury to the extrahepatic biliarydrainage system with bile leakage fol-lowing open cholecystectomy usuallymanifests itself with either bile leakage
234 • JAOA • Vol 97 • No 4 • April 1997 Wenokur and Luby • Case reports
through the incision or around surgicaldrains. Fulminant bile peritonitis fol-lows when the bile becomes secondari-ly infected. Injury was much more sub-tle in our patients because of the absenceof bile drainage (minimal incision and nodrains), and no evidence of bile peri-tonitis was found. When bile is notinfected, there may be very little peri-toneal irritation or very few signs andsymptoms of systemic toxicity.
The unobstructed flow of conjugatednoninfected bile into the peritoneal cav-ity ultimately results in bile ascites, as itdid in our two cases. A significant portionof the bile is absorbed from the peri-toneal surfaces, and because it is fullyconjugated, it will be promptly excretedin the urine.3 The presence of dark urine("cola"-colored) should alert the clini-cian to common duct injury having sub-sequent bile leakage. This sign was eithernot specifically sought out or was notproperly interpreted by our clinicians.
The European experience with lap-aroscopic cholecystectomy revealed a0.2% to 0.6% incidence of common bileduct injury.4 In the United States, in aseries of 84,687 patients, the incidence ofcommon bile duct injury was reported as0% to 1%.3 Comparatively, a 0.5% inci-dence is seen during open cholecystec-tomy.6 A direct correlation has beendemonstrated between the surgeon'sexperience with laparoscopic cholecys-tectomy and the frequency of commonbile duct injury. In the series by Meyerand colleagues,7 they showed that therate of common bile duct injury was2.2% for each surgeon's first 13 cases,which then decreased to 0.1% for sub-sequent cases.
The first axiom of common bile ductinjury is prevention. For prevention, werecommend the following suggestionsadapted from Hunter8 and our ownexperiences (Figure).
Electrocautery is the hemostaticmodality most commonly employed forlaparoscopic cholecystectomy, with manyinjuries attributed to its improper use.The principal causes of electrocauteryinjury are:■ Tissues are inadvertently touched dur-ing current application;
■ direct coupling occurs between theactivated probe and a metal clip thathas been used for hemostasis or occlu-sion; and■ breaks occur in the insulation of theelectrical probe; and■ current passage to adjacent structuresis blocked from recently coagulated, elec-trically isolated tissue, and direct spark-ing of structures occurs from contactwith the activated probe.9
Most electrocautery injuries manifestthemselves within 3 to 7 days with feverand abdominal pain. Note that electro-cautery injury is potentially the mecha-nism in the two cases reported here, butthis could account for only a small partof the delay in diagnosis.
The second axiom of common ductinjury is early recognition. Ideally, allcommon duct injuries would be recog-nized intraoperatively. However, suchis not the case at least 50% of the time.loEarly postoperative recognition willoccur only with a high index of suspi-cion. Any postoperative patient notdoing well at 24 hours or thereaftershould have a thorough evaluationincluding physical examination, com-plete blood cell count, liver functiontests, and hepatobiliary scintigraphy(diisopropyl iminodiacetic acid [DISI-DA], paraisopropyl iminodiacetic acid[PIPIDA]). The use of culdocentesis (asin our patients), while acceptable, hasbeen largely abandoned as the firstchoice of procedures because of the avail-ability of ultrasound and computedtomography (CT) for percutaneousdrainage. Hepatobiliary scintigraphy isconsidered the radiologic test of choicein the evaluation of possible bile leaks.1 1
Computed tomography and ultrasoundcan detect free fluid but cannot offerfunctional or etiologic information.
Percutaneous drainage of bile collec-tions via CT or ultrasound may allow forrepair of the injured biliary duct tobecome an elective, rather than emer-gent, case. The ERCP can offer morespecific information about the source ofthe free fluid compared with CT andultrasound. However, ERCP is techni-cally more difficult to perform than hep-atobiliary scintigraphy, which is con-
sidered more reliable. Other advantagesof ERCP include the ability to place astent in the common bile duct for bilediversion with the potential to avoidmore invasive intraoperative procedures.
CommentOur two cases illustrate the clinical sub-tleties of common bile duct injury asso-ciated with secondary bile leaks withlaparoscopic cholecystectomy. Because ofthese subtle clinical findings, there wasa long delay in diagnosis. The surgeonmust maintain a high index of suspi-cion, even well into the postoperativecourse. It is important to recognize thatuninfected bile does not cause severeperitoneal irritation and that jaundicemay not become clinically evident in theabsence of common duct obstruction.Furthermore, it is important to remem-ber that 50% of injuries go unrecog-nized at the time of operation. Whenany deviation occurs in the clinical coursefrom normal, hepatobiliary scintigraphyis recommended.
5. Gadacz TR: US experience with laparoscopic chole-cystectomy. Am J Surg 1993;165;450-454.
6. Moossa A, Easter D, Vansonnenberg E, et al:Laparoscopic injuries to the common bile duct-A causefor concern. Ann Surg 1992;215;203-208.
7.Meyers WC, Lee, VS, Chad RS, et al: Complicationsof laparoscopic cholecystectomy. Am J Surg1993;165:527-532.
8. Hunter JG: Avoidance of bile duct injury duringlaparoscopic cholecystectomy. Am J Surg 1991;161:71.
9. Nduka C, Super P, Monson J, Darzi A: Cause andprevention of electrosurgical injuries in laparoscopy.Joumal of the American College of Surgeons 1994;179;161-169.
10. Guidelines for credentialing Physicians for laparo-scopic general surgery. OR Manager 1992:6.
11. Berci G: Complications of laparoscopic surgery.Surg Endosc 1994;8:165-166.
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