INCIDENCE AND NATURE OF BILE-DUCT INJURIES FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY - AN AUDIT OF 5913 CASES

The rapid introduction of laparoscopic cholecystectomy has been associ ated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of ia trogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystec tomy in the West of Scotland has been audited prospectively over a 5-y ear period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy i n 19 hospitals submitted prospective data between September 1990 and S eptember 1995. A total of 5913 laparoscopic cholecystectomies were 98. 3 per cent completion of data collection. During this period 37 laparo scopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. I njuries occurred after a median personal experience of 51 (range 3-247 ) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injur ies occurred in 20 of 37 patients, giving an incidence of 0.3 per cent . Five mechanisms for laparoscopic ductal injury were identified, incl uding tenting, confluence and diathermy injuries as well as the classi cal and variant classical types. Ductal injuries were discovered at op eration in 18 patients with consequent repair giving a good clinical o utcome in 17. Contributory factors (severe inflammation, aberrant anat omy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate h igher than that reported previously after open cholecystectomy, althou gh the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mecha nism of injury may lead to yet further reductions in this complication .