MANAGEMENT OF MAJOR BILIARY COMPLICATIONS AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Objective A total of 50 major bile duct injuries after laparoscopic ch olecystectomy were managed by the Duke University Hepatobiliary Servic e from 1990-1992. The management of these complex cases is reviewed. S ummary Background Data Laparoscopic cholecystectomy is the preferred m ethod for removing the gallbladder. Bile duct injury is the most feare d complication of the new procedure. Methods Review of videotapes, pat hology, and management of the original operations were reviewed retros pectively, and the injuries categorized. Major biliary injury was defi ned as a recognized disruption of any part of the major extrahepatic b iliary system. Biliary leakage was defined as a clinically significant biliary fistula in the absence of major biliary injury, i.e., with an intact extrahepatic biliary system. Results Thirty-eight injuries wer e major biliary ductal injuries and 12 patients had simple biliary lea kage. Twenty-four patients had the classic type injury or some variant of the classic injury. A standard treatment approach was developed wh ich consisted of ERCP for diagnosis, preoperative PTC with the placeme nt of stents, CT drainage immediately after the PTC for drainage of bi liary ascites, and usually Roux-en-Y hepaticojejunostomy with placemen t of O-rings for future biliary access if necessary. Major ductal inju ries were high in the biliary system involving multiple ducts in 31 of the 38 patients. Re-operation was required in 5 of the 38 patients wi th particularly complex problems. Conclusions Successful management of bile duct injury after laparoscopic cholecystectomy requires careful understanding of the mechanisms, considerable preoperative assessment by experts, and a multidisciplinary approach.