Laparoscopic Cholecystectomy Complications

Laparoscopic Cholecystectomy Complications

1. Cystic Duct Leaks
1. Etiology
• clips may fail if the cystic duct is gangrenous, thick, or large
• retained common duct stones may raise bile duct pressure, contributing to clip failure
• an unrecognized duct of Luschka may also be a source of bile leakage







2. Clinical Manifestations
• fever, chills, mild jaundice, right upper quadrant pain, bile leakage from incision or drain
• usually presents within a week of surgery


3. Diagnosis
• US or CT will show a right upper quadrant fluid collection or ascites
• HIDA scan, MRCP, or ERCP can be used to identify the site of the leak


4. Management
• ERCP with biliary stent placement is the treatment of choice
• bilomas can usually be managed with percutaneous drains
• occasionally, laparoscopic washout with subhepatic drain placement will be necessary


2. Choledochotomy
1. Etiology
• often results from a lateral dissection injury, usually related to a short cystic duct
• may also occur from a cholangiogram catheter placed in the common duct, usually accompanied by a single clip placed across the common duct


2. Management
• small openings can be closed primarily; larger openings may require T-tube placement
• if a clip was placed, it can be removed – there is only a small chance of developing a stricture
• JP drain placement to control any bile leak


3. Segmental Duct Injuries
1. Etiology
• most commonly involves an aberrant right hepatic duct that is mistaken for the cystic duct


2. Management
• if the duct is smaller than 3 cm, then it can be safely ligated
• since ducts larger than 3 cm are likely to drain multiple liver segments, they should be repaired with a hepaticojejunostomy


4. Major Bile Duct Injury
1. Incidence
• best estimate is 1 injury per 300 laparoscopic cholecystectomies (0.3%)
• open cholecystectomy is associated with a 0.1% injury rate


2. Risk Factors
1. Laparoscopy-Related Factors
• lack of depth perception (2-D image)
• less tactile feedback
• restricted instrument maneuverability
• single-incision lap cholecystectomy seems to be associated with a higher rate of bile duct injuries


2. Surgeon Experience
• 90% of bile duct injuries occur in the first 30 cases for each surgeon


3. Patient-Related Factors
• acute inflammation is associated with a higher injury rate
• chronic inflammation may fuse the gallbladder to the bile ducts and right hepatic artery, making dissection very difficult and contributing to visual misidentification
• aberrant biliary duct anatomy allows for misidentifying an aberrant right hepatic duct as the cystic duct
• morbid obesity


4. Technique-Related Factors
• inadequate inferolateral retraction of the infundibulum
• 30-degree scope may provide better visualization of the triangle of Calot
• difficult dissection may injure underlying or neighboring bile ducts
• avoid blind use of clips or cautery to control bleeding
• tenting injury when clipping a short cystic duct







3. Strategies for Minimizing Bile Duct Injuries (from SAGES)
• use the critical view of safety method for identifying the cystic duct and artery
• use an intraoperative time-out before clipping or cutting any structure
• always consider the possibility of aberrant anatomy
• use cholangiography in difficult cases or if the anatomy is unclear
• switch to another method if conditions are too severe or dangerous
• convert to open
• laparoscopic subtotal cholecystectomy
• cholecystostomy tube
• get help from another surgeon in difficult cases


4. Presentation
• only about 1/3 of serious injuries are identified intraoperatively, usually by seeing bile in the field or by cholangiography
• most of the rest are identified within 30 days of surgery, with the most common symptoms being pain, fever, jaundice, bile leakage


5. Strasberg Major Duct Injury Classification



6. Principles of Management
1. Injury Recognized at the Time of Surgery
• need to convert to an open procedure and get help from another surgeon
• cholangiography is necessary to define the anatomy and type of injury
• the most important initial decision is whether there is a surgeon available who is experienced in complex biliary reconstruction
• if an expert is available, the preferred procedure is resection of the injured segment with Roux-en-Y jejunal limb reconstruction
• if there is no expert available, then drains should be placed and the patient transferred to a referral center


2. Injury Recognized Postoperatively
• best results are obtained when injuries are diagnosed early and patients are referred immediately to experienced centers
• injuries above the bifurcation and vasculobiliary injuries have a worse prognosis than common hepatic or common bile duct injuries


1. Control of Infection
• IV antibiotics
• imaging to identify and drain fluid collections
• with control of sepsis, there is no urgency for biliary reconstruction
• resolution of periportal inflammation increases the likelihood of a successful repair


2. Delineation of Anatomy
• cholangiography is mandatory
• must visualize the bile duct bifurcation and intrahepatic bile ducts
• if the common duct has been transected, PTC is the more useful technique
• PTC will define the anatomy and provide biliary drainage



3. Reestablishment of Biliary-Enteric Continuity
• goal of repair is a tension-free, mucosa-to-mucosa anastomosis with good blood supply
• an end-to-end choledocho anastomosis is associated with a high-rate of stricture formation
• Roux-en-Y hepaticojejunostomy always allows for a tension-free anastomosis and is the standard procedure
• proximal injuries may require a separate anastomosis for each duct
• preoperatively placed transhepatic catheters allow for easier identification of the hepatic ducts
• the catheters may be left in place postoperatively to stent the anastomosis and allow access for imaging



4. Liver Resection
• will be necessary if ductal reconstruction to a part of the liver is impossible
• liver transplantation is required if a failed reconstruction leads to biliary cirrhosis and end-stage liver disease


5. Non-operative Approaches
• chronic strictures associated with an intact duct can often be successfully treated with combined endoscopic and PTC dilation and stenting



5. Bleeding Complications
1. Liver Bed
• in cirrhotics, portal hypertension can result in profuse liver bed bleeding that may require packing to control
• in chronic cholecystitis, the back wall of the gallbladder may be fused to the liver bed, and intrahepatic dissection can result in hemorrhage that requires suture control
• in high-risk situations, it is better to leave the back wall of the gallbladder on the liver bed


2. Arterial Bleeding
• usually results from a misplaced cystic artery clip
• right hepatic artery is also at risk of injury
• control requires direct visualization – blind clipping or cauterization leads to duct injuries


3. Trocar Site Bleeding
• trocars should be removed under direct vision at the end of the case, and a bleeding site should be controlled with open or laparoscopic suturing
• delayed bleeding with hemodynamic instability will require emergent laparoscopy or laparotomy


6. Bowel Injury
1. Etiology
• small bowel injuries may occur during trocar insertion, especially in areas of adhesions
• duodenum and transverse colon injuries are usually thermal or traction injuries


2. Management
• if identified at the time of surgery, some injuries can be repaired laparoscopically; otherwise, laparotomy is required
• if identified postoperatively, then the patient may present with peritonitis and/or sepsis