BILE-DUCT INJURIES DURING LAPAROSCOPIC CHOLECYSTECTOMY - FACTORS THATINFLUENCE THE RESULTS OF TREATMENT

Objective: To analyze the treatment of bile duct injuries during lapar oscopic cholecystectomy to discern the factors affecting outcome. Desi gn: An analysis of the treatment of 88 patients with laparoscopic bile duct injuries. Setting: A university hospital. Patients: Eighty-eight patients with major bile duct injuries following laparoscopic cholecy stectomy. Main Outcome Measures: Success of treatment, morbidity rate, mortality rate, and length of illness. Results: Operations to repair bile duct injuries were unsuccessful in 27 (96%) of 28 procedures when cholangiograms were not obtained preoperatively, and they were unsucc essful in 69% when cholangiographic data were incomplete. In some case s, lack of complete cholangiographic information led to an inappropria te and harmful operation. When cholangiographic data were complete, th e first repair was successful in 16 (84%) of 19 patients. A primary en d-to-end repair over a T tube (13 patients) was unsuccessful in every case in which the duct had been divided. Direct closure of a partial d efect in the duct was successful in four of seven patients. Fifty-four (63%) of 84 Roux-en-Y hepaticojejunostomies were successful. Factors responsible for the unsuccessful outcomes were the following: incomple te excision of the scarred duct, use of nonabsorbable suture material, use of two-layer anastomosis, and failure to eradicate subhepatic inf ection before the attempted repair. Dilatation and stenting was unifor mly unsuccessful as primary treatment (three patients) and was success ful in only seven of 26 patients following a previous operative repair . Patients first treated by the primary surgeon had an average length of illness of 222 days (P<.01). Only 17% of primary repair attempts an d no secondary repair attempts performed by the laparoscopic surgeon w ere successful. Patients whose first repair was performed by tertiary care biliary surgeons had a length of illness of 78 days (P<.01), and 45 (94%) of 48 repairs by tertiary care biliary surgeons were successf ul. Conclusions: Surgeons who specialize in the repair of bile duct in juries achieve much better results than those with less experience. Th e worse results of other surgeons could be attributed in many instance s to specific correctable errors. Nonsurgical treatment was usually un successful and substantially increased the duration of disability.