Laparoscopic bile duct injuries. Risk factors, recognition, and repair
R. L. Rossi, W. J. Schirmer, J. W. Braasch, L. B. Sanders and J. L. Munson
Department of General Surgery, Lahey Clinic Medical Center, Burlington, Mass. 01805.
Records of 11 patients undergoing biliary reconstruction after laparoscopic
cholecystectomy are reviewed. Ductal injuries resulted from failure to
define the anatomy of Calot's triangle. Risk factors include scarring,
acute cholecystitis, 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.
