Bile duct injuries during laparoscopic cholecystectomy: A collective experience of four teaching hospitals and results of repair

Background: Laparoscopic cholecystectomy has been performed in Singapore si nce 1990 and, up until the end of 1997, a total of 4445 procedures had been performed in the four major teaching hospitals. Although bile duct injurie s were thought to have increased following the introduction of laparoscopic cholecystectomy, there have been no reviews done on the incidence of these injuries in the Singapore context. Methods: The present retrospective review aimed to audit the rate of bile d uct injuries in the four major teaching hospitals in Singapore and to docum ent the results of management of these injuries. Results: Of the 4445 procedures performed, there were 19 (0.43%) cases of b ile duct injuries. These involved the common hepatic duct (n = 8), common b ile duct (n = 10), and the right hepatic duct (n = 1). The underlying gall bladder pathology included non-inflamed gall bladders (n = 10), acute chole cystitis (n = 4), Mirrizzi's syndrome (n = 3) and mucocele of the gall blad der (n = 2). Transection of the duct accounted for the majority of the inju ries. Eleven bile duct injuries were identified at the time of operation. T hese were primarily repaired over a T tube (n = 4) or by a bilio-enteric by pass (n = 7). The remainder were diagnosed at a median of 7 days (range: 1- 556 days) after surgery with a presentation of jaundice or pain. These were repaired by bilio-enteric anastomosis (n = 7) and closure over a T tube (n = 1). Three patients developed strictures subsequently, two following bili o-enteric repair after delayed diagnosis and one following immediate primar y repair over a T tube. One patient developed intrahepatic stones and requi red a left lateral segmentectomy. Conclusions: The experience of a 0.43% bile duct injury rate is comparable to the best results from most large series in the West. Inflammation at Cal ot's triangle is an important associated factor for injury. Early recogniti on and prompt repair affords good results, and hepaticojejunostomy is recom mended as the repair of choice.