BILE-DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY - MECHANISM OF INJURY, PREVENTION, AND MANAGEMENT

Although several studies have shown a low incidence of bile duct injur ies during laparoscopic cholecystectomy, concerns remain because of th e sustained increase in the number of referrals for biliary reconstruc tion after the procedure. Twenty-one patients have been referred to ou r institution because of major bile duct injuries after laparoscopic c holecystectomy. The injury was recognized during the laparoscopic proc edure in only 6 of the 21 (29%). Nineteen patients underwent hepaticoj ejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcati on was required in 10 patients (50%), at the bifurcation in 3, and bel ow the bifurcation in 7. Nine of the eleven patients in whom the initi al repair was performed at the local hospital presented with early str icture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps d uring laparoscopic cholecystectomy to avoid bile duct injuries are des cribed. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.