Infundibular laparoscopic cholecystectomy method requires a quality renewal: 18 year 13 274 cholecystectomy analysis with assessment of 45 iatrogenic bile duct injuries
Background
This is an audit of the incidence of bile duct injury (BDI) in emergency and elective laparoscopic as well as open cholecystectomies in Vilnius Republican University Hospital from 1996 till 2013. We used these results to estimate the risk of the iatrogenic bile duct injury related to laparoscopic cholecystectomy (LC).
Methods
Information was retrieved from hospital databases, annual reports, and personal records. The standard infundibular technique and the use of metalic clips for a laparoscopic cholecystectomy was employed routinely. The Bismuth–Strasberg classification was used to describe the bile duct injuries as follows: A (a leaking cystic, segmental or Luschka duct), B (lobar or
sectorial bile duct injury without bile leak), C (lobar or sectorial bile duct injury with bile leak), D (perforation of common hepatic duct (CHD) or common bile duct (CBD), and E (transsection, full compression or stricture of CHD or CBD). Standard statistical univariate and multivariate logistic regression analysis methods were employed.
Results
During the study period, a total of 13,274 cholecystectomies were performed. Of these 11,189 (84%) were performed laparoscopically
while the remainder 2085 (16% ) were open. Of the total number of 13,274 cholecystectomies, 5241 (39.5%) were performed in the emergency setting, the remainder being elective cases. Overall, there were 45 BDIs identified, of which 42 were related to a LC. Forty two of them were related to a LC. The incidence of BDI was 2.7 times higher in the laparoscopic surgery group compared to the open surgery group (0.38% vs 0.14%, OR 2.6149, 95% CI 0.8097–8.4442, z = 1.607, p = 0.1080). Furthermore, the incidence of BDI in patients undergoing emergency cholecystectomy was twice that of those having elective surgery (0.5% vs 0.24%, OR 2.1029, 95% CI 1.1627–3.8034, z = 2.459, p = 0.0140). Of the 45 BDIs which occured during the study period, 19 (42.2%) were identified during the index surgery, the remaining 26 (57.8%) were diagnosed in the postoperative period. An urgent postoperative ERCP was the definitive diagnostic tool for 24 (92.3%) of those 26 patients. The Bismuth–Strasberg D class bile duct injury was most the frequent – 18 cases (40.0%), followed by A (13 cases, 28.9%), E (11 cases,
24.4%), and C (3 cases, 6.7%). Bile duct stenting was a definitive curative procedure for 20 patients of those who underwent an ERCP. Open reconstructive bile duct surgery was performed for the remaining 25 patients. The overall hospital mortality rate for patients who sustained a BDI was 11.1% (5/45). No independent risk factors for mortality were identifed. The overall estimated risk of BDI related to a LC was 1:261. The estimated risk for a class-specific BDI related to a LC was as follows: 1:323 for A, 1:247 for D, 1:1243 for E, and 1:1400 for C. The estimated risk for any injury of CHD or CBD (D and E classes) was 1:430.
Conclusions
Bile duct injury in LC is an uncommon but serious complication of cholecystectomy. In our series, the incidence of BDI was higher in patients undergoing LC compared to open cholecystectomy, and in those having emergency surgery. The development of safe surgical practise in LC is a requirement in all institutions admitting patients with biliary disease. We propose a step-wise approach of 25 principles to minimize risk to patients.