BILE-DUCT INJURY FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY - REFERRAL PATTERN AND MANAGEMENT

Background Laparoscopic cholecystectomy is associated with a higher in cidence of bile duct injury than open cholecystectomy. This study revi ews the management of bile duct injury in a tertiary hepatobiliary uni t. Methods From 1991 to 1995, 27 patients (18 women) of median age 49 (range 25-67) years were referred to this unit with bile duct injury f ollowing elective laparoscopic cholecystectomy. Laparoscopic cholecyst ectomy was described as 'uneventful' in 14 and 'difficult' in 13 patie nts, six injuries were recognized at operation. Results Patients were transferred a median of 26 (range 0-990) days after laparoscopic chole cystectomy, although initial symptoms were recorded a median of 3 (ran ge 0-700) days after cholecystectomy. Fifteen patients underwent addit ional surgery before referral. Management before referral included sur gical exploration (15 patients), endoscopic cholangiography (ERC) and stent insertion (three), external drainage of bile collections (five), and conservative management (five). Management after referral include d surgical reconstruction (19 patients), laparotomy with drainage (one ), percutaneous drainage (two), ERC and stent insertion (two), percuta neous cholangiography with dilatation and stent placement (three), and conservative management (two). One patient died and the median inpati ent stay following referral was 14 (range 7-78) days. Ten of 15 patien ts who had surgery before referral required a further biliary reconstr uction. After median follow-up of 30 (range 3-60) months, four of nine patients with complex high injuries continue to have episodes of chol angitis: and one patient has developed secondary biliary cirrhosis. Co nclusion Bile duct injury following laparoscopic cholecystectomy is a complex management problem and results in significant postoperative mo rbidity. Most patients referred after attempted repair require further reconstructive surgery, and patients with complex high injuries have a risk of long-term morbidity.