BILE-DUCT INJURY DURING LAPAROSCOPIC CHOLECYSTECTOMY - A PROSPECTIVE NATIONWIDE SERIES

BACKGROUND: The risk of bile duct injury in laparoscopic cholecystecto my has been a concern since the procedure became part of the surgical armamentarium. Our study assesses the incidence, types, and treatment for laparoscopic bile duct injury. STUDY DESIGN: Prospective case regi stration in a national database with participation by all departments of surgery performing laparoscopic cholecystectomy in Denmark since th e first operation in January 1991. The case notes for bile duct injury have been reviewed. RESULTS: From 1991 through 1994, 57 of 7,654 pati ents sustained bile duct injury (0.74 percent; 95 percent confidence i nterval, 0.55 percent to 0.94 percent), including nine injuries occurr ing after conversion. The annual incidence did not decrease. Thirty-ni ne percent of the laparoscopic bile duct injuries were incisions, 39 p ercent were transections, and 12 percent were clip injuries or strictu res. One patient, who sustained transection during open reoperation fo r bleeding after a converted procedure, died. Bile leaks for reasons o ther than bile duct injury occurred in 2.1 percent; 71 percent of thes e were cystic duct leaks. Acute cholecystitis was the indication for l aparoscopic cholecystectomy in 968 patients, with 1.3 percent sustaini ng laparoscopic bile duct injury (95 percent confidence interval, 0.62 percent to 2.08 percent), while the incidence in patients with other indications for laparoscopic cholecystectomy was 0.62 percent (95 perc ent confidence interval, 0.44 percent to 0.82 percent) (p>0.05). Preop erative knowledge of bile duct anatomy was available by means of preop erative endoscopic retrograde cholangiopancreatography or intravenous cholangiography in 26 percent of patients undergoing laparoscopic chol ecystectomy but this did not reduce the risk of bile duct injury. The frequency of bile duct injury in patients who had intraoperative chola ngiography was not significantly different from those who did not. Int raoperative cholangiography was done in 14 cases of injury (diagnostic for injury in 8, misinterpreted in 2, and normal in 4 patients), The case notes described operative difficulties in 11 of 48 cases of lapar oscopic bile duct injury, most often because of fibrosis or difficulty delineating the anatomy. CONCLUSIONS: The incidence of bile duct inju ry in laparoscopic cholecystectomy is higher than previously generally anticipated and did not decrease from 1991 through 1994. Risk factors and possible preventive measures should be evaluated in prospective s tudies.