Surgical repair after bile duct and vascular injuries during laparoscopic cholecystectomy: When and how?

Recent collective reviews have outlined when and how surgeons should treat patients with bile duct injuries after laparoscopic cholecystectomy (LC). H owever, little is described about other injuries combined with bile duct in juries, for example, hepatic arterial injury and secondary biliary cirrhosi s. Fifteen patients with bile duct injuries following LC were referred and surgically treated from 1990 to 1998 in our institution. We report how pati ents with hepatic arterial injury combined with bile duct injuries during L C were treated. The present study also reports unusual complicated situatio ns: one patient with biliary cirrhosis referred 4 years after LC, another t reated with internal biliary metallic stent referred 2.5 years after LC, an d another with isolated right hepatic ductal injury. Short- and long-term s urgical outcomes after biliary repair were compared between simply referred patients and those with complicated history. Patients who were referred se veral years after LC and who were referred after primary hepaticojejunostom y were included with patients with complicated history (n = 4, group B), an d the other patients were included with patients with simple history (n = 1 1, group A). Simultaneous right hepatic arterial occlusion was observed in 3 of these 15 patients, and arterial reconstruction was performed in 2 of t he 3 patients in addition to biliary reconstruction. No postoperative compl ication occurred in these three patients. The patient with isolated injury of the right hepatic duct and the other with biliary cirrhosis were success fully treated with hepaticojejunostomy. The other patient treated with bili ary stent underwent hepaticojejunostomy but a second operation was required because of later stenosis. Mean hospital stay was significantly longer in group B (30.3 +/- 6.9 days) than in group A (18.5 +/- 2.5 days, p < 0.05). Rehospitalization was more frequent in group B than in group A (P < 0.01). However, long-term outcome was successful in both groups. The present resul ts showed that arterial reconstruction should be performed when the distal right hepatic artery can be exposed and reconstructed, and suggested that p atients with bile duct injuries during LC should be immediately referred to surgical institutions in which surgeons have adequate experience of bile d uct repair and hepatic arterial reconstruction.