LAPAROSCOPIC BILIARY INJURY - MORE THAN A LEARNING-CURVE PROBLEM

Background: The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduct ion of laparoscopic cholecystectomy (LC) has been explained as a 'lear ning curve' problem. The early New Zealand experience has been publish ed and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscop ic biliary injuries (LBI) after further experience with LC. Methods: A nationwide audit was undertaken in 1995 by two confidential postal qu estionnaires: to all active general surgeons (n = 184, response rate 6 0%), and to all endoscopists performing endoscopic retrograde cholangi opancreatography (ERCP) (n = 18, response rate 100%). Results: The tot al number of LBI was 21, compared with 41 for 1991-92. The site and na ture of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeon s responsible for the LBI there was no apparent decrease in the incide nce of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a signifi cant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patie nts with minor injuries managed by re-operation (26% vs 50%). Conclusi ons: The present study indicates that iatrogenic biliary injury is a p ersistent problem in New Zealand, despite increasing experience with L C, and suggests the need for more intensive scrutiny of operative tech nique and training. There is scope to manage more patients with minor duct injuries conservatively.