Diseases of the Gallbladder and Bile Ducts - part 5 potx

Extensive resection of the bile ducts combined with liver resection for cancer of the main hepatic duct junction: a cooperative study of the Keio Bile Duct Cancer Study Group.. Extended

168 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

carefully reviewed by an experienced pathologist to evaluate

the degree of tumor infiltration The surgical approach

de-pends on the depth of tumor invasion in the gallbladder wall

and major liver resection might be necessary

If the tumor is limited to the mucosa (carcinoma in situ) a

simple cholecystectomy is sufficient, offering excellent

long-term survival (see Chapter 15) If the tumor infiltrates the

muscularis propria without reaching the gallbladder serosa,

an extended cholecystectomy (gallbladder resection plus

wedge resection of the liver) with dissection of the lymphatic

tissue of the hepatoduodenal ligament is the therapy of

choice Therefore, the gallbladder plus a 1- to 3-cm wedge

re-section of the gallbladder bed are resected with a frozen

sec-tion of the resecsec-tion margin of cystic duct If the intraoperative

cystic duct biopsy is positive for tumor, a complete resection

of the choledochal duct and common hepatic duct up to the

bifurcation with the surrounding lymphatic tissue has to be

added to the procedure

For gallbladder carcinoma found during or after a scopic cholecystectomy, we recommend excising the port sites The incidence of port sites metastases was found to be between 14 and 16% independent from the extend of the gallbladder cancer [29,30] In addition, in cases with gall-bladder perforation during laparoscopic cholecystectomy the incidence of port site metastases has been as high as 40%.More extensive resections are indicated if the tumor ex-tends beyond the gallbladder serosa Extended right hemi-hepatectomy or central hepatectomy, including segments IVb and V together with a resection of the cystic duct, com-mon bile duct, and the lymphatic tissue, are often used to achieve tumor clearance The prognosis and results of the different approaches are discussed in detail in Chapter 15

laparo-If a curative resection is not possible due to a large tumor load or extensive involvement of the liver hilum, then sur-gery is not a therapeutic option The prognosis of patients with unresectable gallbladder cancer is poor and the therapy should focus on minimal invasive approach (percutaneous

or endoscopic; see Chapters 5 and 6) and supportive care The results of each therapeutic approach mentioned above will be discussed in detail in Chapter 15

Reconstruction of the biliary outflow

Reconstruction of the biliary outfl ow is necessary after tion of cholangiocarcinoma and sometimes after resection of

resec-a gresec-allblresec-adder cresec-ancer More rresec-arely, bypresec-ass procedures resec-are quired for malignant or benign strictures Endoscopic and percutaneous drainage procedures are described in Chapters

re-5 and 6 In this section we will focus on surgical procedures for biliary reconstruction

The goal of biliary reconstruction is to relieve jaundice, prevent cholangitis, and to avoid recurrent biliary stricture

A Roux-Y anastomosis is performed in most cases to sure good blood supply of a wide mucosa-to-mucosa anasto-mosis between all transected bile ducts and a Roux-en-Y jejunum limb

en-Although drainage of one side of the biliary tree is cally sufficient to relieve jaundice, the jejunal limb should drain all parts of the liver to prevent cholangitis The princi-ples of reconstruction are: (1) identifi cation of healthy bile duct mucosa proximal to the stenosis/transection; (2) prepa-ration of a Roux-en-Y loop of usually 40 to 60 cm in length; and (3) direct mucosa-to-mucosa anastomosis Whether a biliodigestive anastomosis should be stented by a drain re-mains controversial There is no proven benefit for stenting, and we do not insert anastomotic stents

theoreti-The most common biliodigestive drainage is the side hepaticojejunostomy The Roux-en-Y jejunal limb is di-rectly anastomosed to the hepatic bifurcation draining both lobes of the liver If a major hilum resection has been per-formed, the Roux-en-Y limb can also be anastomosed

end-to-Figure 8.4 After transection the bile duct is elevated and separated

from the hepatic artery and the portal vein.

Chapter 8: Surgery of the biliary system 169

directly to segmental ducts (Fig 8.5) Biliodigestive

anasto-moses are performed with absorbal monofilament sutures

(e.g PDS 5.0) The sutures of the anterior layer are performed

first, prior to any attempt to place the posterior row If more

than one orifice is present then all anterior row sutures have

to be placed before any posterior row can be placed Each

an-terior suture is placed full thickness from the inside to the

outside, from left to right When the entire row is placed, the

anterior sutures are elevated and the corner sutures are held

tight (Fig 8.6) Then the sutures of the posterior row are

sub-sequently tied with the nodes outside or inside the lumen

Fi-nally, the anterior row is completed by suturing the anterior

jejunal side from the inside to the outside

If the hepatic hilum is not accessible for the biliodigestive

anastomosis then the left common hepatic duct is the second

choice [31,32] The left main hepatic duct has a long tal extrahepatic course, which can easily be reached in most cases Division of the ligamentum teres from the abdominal wall to the diaphragm is necessary A solid tie has to be placed

horizon-on the ligament to allow elevatihorizon-on and tractihorizon-on Then the renchymal bridge connecting the left and the quadrate lobe is transected by diathermy The Glisson’s capsule at the base of segment IV of the liver is dissected and the main left bile duct

pa-is exposed (Fig 8.7) From thpa-is point the dpa-issection can be extended to the right side in order to include the confluence

or the right hepatic duct into the anastomosis A side-to-side anastomosis to a Roux-en-Y loop is performed as described above

Most biliodigestive anastomosis can be performed by a hilum or left duct approach If neither option is possible, then

Common segmental hepatic duct stomata

Detail

Portal vein Proper hepatic

artery

Intrahepatic cholangiojejunostomy

Figure 8.5 The biliodigestive anastomosis is

facilitated if small segmental ducts are sutured

together and connected in one anastomosis.

170 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

(A)

(B)

Figure 8.6 (A) At first, the sutures of the anterior

row are placed in full thickness and the sutures are

elevated (B) Then the posterior row is performed

from the right side to the left side Finally, the anterior row is completed.

Figure 8.7 The left hepatic duct is exposed after transection of the

Glisson capsule at the base of S IV of the liver The horizontal

extrahepatic course allows a wide Roux-en-Y anastomosis.

the round ligament approach is the next option [33] The amentum teres is divided and the parenchymal bridge be-tween segment IV and the left lobe is transected Then the liver is lifted up and the ligamentum teres stump is pulled downwards The left base of the ligamentum teres is transect-

lig-ed and the duct for segment III is exposlig-ed above and behind the portal vein and a side-to-side anastomosis with a Roux-en-Y loop can be performed (Fig 8.8)

In 1949, Longmire described [34] an approach to the ment II duct in presence of extensive strictures of the left and right hepatic duct The Longmire procedure is often less ef-fective than the other methods, and involves liver resection with an increased risk of bleeding The left lateral sector of the liver is mobilized A clamp is placed across the left lateral segment next to the ligamentum teres A wedge resection of the left lateral sector is performed exposing the ducts of seg-ment II Careful release of the clamp allows identifi cation of the vessels, which are selectively ligated The branches of the portal vein run in close proximity to the bile ducts and bleed-ing has to be controlled carefully without compromising the lumen of the ducts Then, an end-to-side anastomosis with a Roux-en-Y loop can be performed

seg-Occasionally, the right side of the liver has to be approached for drainage A wedge resection of segments V or VI can be performed, exposing the underlying ducts Similarly, a cho-lecystectomy and incision of the gallbladder fossa has been described to expose the duct of segment V [35] However, with the advances of percutaneous transhepatic biliary drainage during the last decade, surgical drainage proce-dures using the segmental bile ducts are only rarely indicated today

Chapter 8: Surgery of the biliary system 171

Questions

1 Which of the following is not a major goal of biliodigestive

bypass in patients with malignant biliary obstruction?

a improvement of quality of life

b improvement of nutritional status

c relief of jaundice

d avoidance of cholangitis

e prevention of recurrent bile duct obstruction

2 Which of the following surgical procedures is never

acceptable as oncologic resection of a common bile duct

e extended partial hepatectomy + extrahepatic bile duct

resection in bloc with gallbladder and lymphatic tissue

3 Which is not a risk factor for surgical intervention of the biliary

system?

a advanced vascular disease

b chronic liver disease

c cardiac disease

d pulmonary disease

e being overweight

4 Which is not a potential advantage of preoperative biliary

drainage in jaundice patients before hepatectomy?

a decrease in the risk for postoperative liver failure

b improvement of long-term survival

c facilitates an intraoperative cholangiogram

d intraoperative palpation of the catheter in the liver hilum

e restores intestinal barrier function in patients with internal bile duct drainage

5 Which is the gold standard to asses hepatic artery involvement

in a patient with Klastkin tumor?

a abdominal computed tomogram

b abdominal magnetic resonance imaging

c endoscopic retrograde choledochopanceaticography (ERCP)

d abdominal ultrasound

e liver angiography

6 Which of the following should not be considered as a

contraindication for major liver surgery?

a ongoing infection

b coagulopathy

c child C cirrhosis

d acute hepatitis

e advanced age (>80 years old)

7 A nasoenteral feeding tube should be placed before major liver

resection in the following situation:

a in all cases

b only in selected cases with malnutrition status

c never

d only in patients with acute cholangitis

e only associated with percutaneous or endoscopic biliary drainage

8 All of the following are absolute contraindications for surgery in

patients with Klatskin tumor except

a encasement of the main portal vein

b encasement of the hepatic artery

c vascular involvement of the left and right branches of the hepatic artery

d vascular involvement of hepatic artery major branch with simultaneously major bile duct involvement of the contra lateral side

e vascular involvement of more than four segments of the liver

Figure 8.8 The liver is pulled up and the ligamentum teres downwards

The duct of S III can be approached by dissecting the left part of the base

of the ligamentum teres A side-to-side Roux-en-Y anastomosis can be

performed.

172 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

9 In a patient with tumor progression beyond the second

bifurcation on the left or right side (Bismuth III) the adequate

surgical strategy is

a bile duct resection + hemihepatectomy or extended

hemihepatectomy including segment 1

b hemihepatectomy or extended hemihepatectomy including

segment 1

c bile duct resection + resection of liver segment 1

d bile duct resection with Whipple procedure

e central hepatectomy

10 Which of the following radiological evaluations should not be

included in the preoperative work up of a patient with distal

obstruction of the bile duct

a computed tomogram

b magnetic resonance imaging

c endoscopic retrograde choledocho-pancreaticography (ERCP)

d abdominal ultrasound

e percutaneous transhepatic cholangiogram

11 In a patient with a gallbladder carcinoma infiltrating the

muscularis propria without reaching the gallbladder serosa and

negative margin in the cystic duct, the adequate strategy to

achieve tumor clearance is

a only cholecystectomy

b extended cholecystectomy (gallbladder resection plus wedge

resection of the liver)

c extended cholecystectomy + dissection of the lymphatic tissue

of the hepatoduodenal ligament

d extended cholecystectomy + complete resection of the

choledochal duct and common hepatic duct up to the

bifurcation with the surrounding lymphatic tissue

e complete resection of the choledochal duct and common

hepatic duct up to the bifurcation with the surrounding

lymphatic tissue

12 Regarding biliodigestive bypass in patients with malignant

obstruction, which of the following is incorrect?

a jejunum derivations should be preferred rather than duodenal

derivations

b a Roux-en-Y jejunal limb should be always preferred

c anastomosis should be done mucosa-to-mucosa

d transanastomotic biliary stent should always be placed

e the most common procedure is the end-to-side

5 Cherqui D, Benoist S, Malassagne B, et al Major liver resection for carcinoma in jaundiced patients without preoperative bili- ary drainage Arch Surg 2000;135:302–8.

6 Hatfield ARW, Terblanche J, Fataar S, et al Preoperative nal biliary drainage in obstructed jaundice Lancet 1982;23: 896–9.

exter-7 McPherson GAD, Benjamin IS, Hodgson HJF, et al operative percutaneous transhepatic biliary drainage: the results of a controlled trial Br J Surg 1984;71:371–5.

Pre-8 Kawarada Y, Higashiguchi T, Yokoi H, et al Preoperative biliary drainage in obstructive jaundice Hepatogastroenterology 1995; 42:300–7.

9 Takahashi K, Ogura Y, Kawarada Y Pathohysiological changes caused by occlusion of blood flow into the liver during hepatec- tomy in dogs with obstructive jaundice J Gastroenterol Heatol 1996;11:963–70.

10 Kamiya S, Nagino M, Kanazawa H, et al The value of bile replacement during external biliary drainage: an analysis of intestinal permeability, integrity, and microflora Ann Surg 2004;239:510–7.

11 Dobay K, Freier D, Albaer P The absent role of prophylactic biotics in low-risk patients undergoing laparoscopic cholecytec- tomy Am Surg 1999;65:226–8.

anti-12 Higgins A, London J, Charland S, et al Prophylactic antibiotics for elective laparoscopic cholecystectomy Arch Surg 1999;134: 611–4.

13 Larraz-Mora E, Mayol J, Martinez-Sarmiento J, et al Open biliary tract surgery: multivariate analysis of factors affecting mortality Dig Surg 1999;16:204–8.

14 Selzner M, Clavien PA Resection of liver tumors: Special emphasis on neoadjuvant and adjuvant therapy In: Clavien PA,

ed Malignant liver tumors: Current and emerging therapies Malden, MA: Blackwell Science, 1999: 137–49.

15 Nakayama F, Miyazaki K, Naggafuchi K Radical surgery for middle and distal thirds bile duct cancer World J Surg 1988; 12:60–3.

16 Sugiura Y, Nakamura S, Iida S, et al Extensive resection of the bile ducts combined with liver resection for cancer of the main hepatic duct junction: a cooperative study of the Keio Bile Duct Cancer Study Group Surgery 1994;115:445–51.

17 Stain S, Parekh D, Selby R Tumors of the gallbladder and the biliary tract In: Kaplowitz N, ed Biliary disease Los Angeles: Williams & Wilkins, 1996:725–38.

18 Blumgart L, Benjamin I, Hadjis N, Beazley R Surgical

approach-es to cholangiocarcinoma at confluence of hepatic ducts Lancet 1984;14:66–9.

19 Blumgart L Cancer of the bile ducts In: Blumgart L, ed Surgery

of the liver and biliary tract New York: Churchill Livingston; 1994:829–53.

Chapter 8: Surgery of the biliary system 173

20 Nimura Y, Hayakawa N, Kamiya J, et al Hepatic segmentectomy

with caudate lobe resection for bile duct carcinoma of the

hepat-ic hilus World J Surg 1990;14:535–44.

21 Launois B, Terblanche J, Lakehal M, et al Proximal bile duct

cancer: high resectability rate and 5-tear survival Ann Surg

1999;230:266–75.

22 Klempnauer J, Ridder G, Wasielewski R, et al Resectional

sur-gery of hilar cholangiocarcinoma: A multivariate analysis of

prognostic factors J Clin Oncol 1997;15:947–54.

23 Tashiro S, Tsuji T, Kanemitsu K, et al Prolongation of survival

for carcinoma at the hepatic duct confluence Surgery 1993;113:

270–8.

24 Tsuzuki T, Ueda M, Kuramochi S, et al Carcinoma of the main

hepatic junction: Indications, operative morbidity and

mortali-ty, and long-term survival Surgery 1990;108:495–501.

25 Bismuth H, Caistaing D, Traynor O Resection or palliation:

Priority of surgery in the treatment of hilar cancer World J Surg

1988;12:39–47.

26 Mizumoto R, Kawarada Y, Suzuki H Surgical treatment of hilar

carcinoma of the bile duct Surg Gynecol Obstet 1986;162:

153–8.

27 Pinson W, Rossi R Extended right hepatic lobectomy, left

hepat-ic lobectomy, and skeletonization resection for proximal bile

duct cancer World J Surg 1988;12:52–9.

28 Selzner M, Clavien P-A Resection of liver tumors: special

em-phasis on neoadjuvant and adjuvant therapy In: Clavien P-A,

ed Malignant liver tumors-Current and emerging therapies Malden, MA: Blackwell Science, 1999:137–49.

29 Z’gragger K, Birrer S, Maurer C, Wehrl H, Klaiber C, Baer H cidence of port site recurrence after laparoscopic cholecystecto-

In-my for preoperatively unsuspected gallbladder carcinoma Surgery 1998;124:831–8.

30 Lundberg O, Kristoffersson A Port site metastases from bladder cancer after laparoscopic cholecystectomy Results of a Swedish survey and review of published reports Eur J Surg 1999;165:215–22.

gall-31 Hepp J Hepaticojejunostomy using the left biliary trunk for rogenic biliary lesions: the French connection World J Surg 1985;9:507–11.

iat-32 Hepp J, Moreaux J, Lechaux JP [Intrahepatic bilio-digestive anastomosis in biliary tract cancers Results of 62 operations] Nouv Presse Med 1973;2:1829–32.

33 Hepp J, Pernod R, Hautefeuille P [Anastomoses using the left hepatic duct in reparative biliary surgery.] Mem Acad Chir (Paris) 1962;88:295–9.

34 Longmire W, Sandford M Intrahepatic cholangiojejunostomy with partial resection of the liver Surgery 1949;128:330–47.

35 Lygidakis N, Heyde M Surgical management of malignancies of the biliary tree In: Lygidakis N, Tytgat G, eds Hepatobiliary and pancreatic malignancies New York: Thieme; 1989:341–63.

C H A P T E R 9 Laparoscopic treatment for diseases of the gallbladder and biliary tree

Stefan Wildi, Sarah K Thompson, John G Hunter and Markus Weber

9

O B J E C T I V E S

• Name the different clinical presentations for cholecystolithiasis, acute cholecystitis, cholangitis, and choledocholithiasis

• List the different diagnostic investigations

• Know the correct technique of laparoscopic cholecystectomy and its pitfalls

• Describe additional investigations and procedures in special cases

• Know how to deal with special anatomical findings

Introduction

In the year 1985, the German surgeon Erich Mühe was the

first to perform a laparoscopic cholecystectomy [1] This was

only possible after several technical developments in the

past, starting with the first laparoscopy in humans by Kelling

in 1902 and Jacobaeus in 1910 [2,3] In 1988, laparoscopic

cholecystectomy was introduced in the USA by Reddick et al

[4] Unlike other technical developments in surgery,

laparo-scopic cholecystectomy rapidly spread throughout the world

and gained wide acceptance by surgeons Today, laparoscopic

cholecystectomy has become the gold standard in the

treat-ment of gallbladder disease

Symptomatic cholecystolithiasis

The incidence of cholelithiasis is approximately 10% in the

United States, of which 10 to 15% of patients will become

symptomatic [5] The patients usually present with acute,

colicky pain in the upper abdomen, typically after fatty

meals In addition, nausea and vomiting can occur However,

some patients only report vague complaints of the upper right

abdomen Diagnostic work-up consists of laboratory

investi-gations with special emphasis on bilirubin and alkaline

phosphatase and an ultrasound of the abdomen (Table 9.1)

These investigations lead to the correct diagnosis in almost all

cases Additional examinations, such as computed

tomogra-phy (CT scan) or gastroscopy, might be needed in order to

rule out other diseases (e.g acute gastritis, tumor formation)

Uncomplicated cholelithiasis can be treated conservatively

174

with painkillers, and an elective laparoscopic

cholecystecto-my is performed later When no operation is done in the follow-up of patients with mild symptoms, the rate of devel-oping complicated cholelithiasis is slightly higher with up to 3% per year compared to 1 to 2% of patients with asymp-tomatic stones [5] If the patient’s history (jaundice, acute pancreatitis) and/or the laboratory investigations suggest choledocholithiasis (increased bilirubin or alkaline phospha-tase), a preoperative endoscopic retrograde cholangiopan-creatography (ERCP) is indicated to clear any stones from the bile ducts and to confirm the diagnosis If no strong evidence for common bile duct stones is present, such as elevated bili-rubin and alkaline phosphatase or dilated intrahepatic bile ducts in the ultrasound, preoperative ERCP is not necessary and can be performed postoperatively, if there is a suspicion

of stones remaining in the bile duct [6] Intravenous giography before surgery to detect choledocholithiasis or ab-normal bile duct anatomy has not shown a benefit and is no longer justified [7–9] As an alternative to the invasive ERCP,

cholan-a mcholan-agnetic resoncholan-ance cholcholan-angiopcholan-ancrecholan-atogrcholan-aphy (MRCP) can be performed to investigate the biliary tree Especially in patients after previous upper abdominal surgery, such as Roux-en-Y reconstruction, it might be very difficult or even impossible to get an ERCP In these special cases, MRCP can

be very helpful However, MRCP has no therapeutic options

Acute cholecystitis

In contrast to symptomatic cholecystolithiasis, patients fering from acute cholecystitis present with a permanent

suf-Diseases of the Gallbladder and Bile Ducts: Diagnosis and Treatment, Second Edition

Edited By Pierre-Alain Clavien, John Baillie Copyright © 2006 by Blackwell Publishing Ltd

Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 175

pain and tenderness in the right upper abdomen, also known

as Murphy sign In addition, fever can occur Laboratory

re-sults reveal a leukocytosis and an elevation of C-reactive

pro-tein (CRP) Bilirubin usually remains normal and therefore

allows differentiation from an acute cholangitis that presents

with the classical Charcot triad (i.e fever, pain, elevated

bili-rubin) The ultrasound of the abdomen shows a thickened

wall of the gallbladder, but this finding also might be absent

Only in case of a Mirizzi’s syndrome, with external

compres-sion of the common bile duct by a stone located in the cystic

duct, might acute cholecystitis be accompanied by jaundice

Choledocholithiasis

Choledocholithiasis is present in 5% of all patients

undergo-ing laparoscopic cholecystectomy [10,11] In an interestundergo-ing

prospective study, Collins et al demonstrated that more than

one-third of these stones pass spontaneously within 6 weeks

after operation and do not need any further treatment [11]

In these patients, intraoperative cholangiography might

eas-ily lead to an invasive overtreatment with ERCP or even open

common bile duct (CBD) exploration With the low incidence

of CBD stones and the excellent treatment possibilities for

symptomatic CBD stones by ERCP, the routine use of

intraop-erative cholangiography can no longer be recommended (see

also below) [12–15]

Indications for laparoscopic

cholecystectomy

The indications for laparoscopic cholecystectomy do not

dif-fer from those for the open technique Symptomatic

choleli-thiasis remains the most frequent reason to perform a

cholecystectomy In acute cholecystitis, the optimal time

point of surgery is still under debate Most surgeons

pre-fer an operation within 48 to 72 hours after the onset of

symptoms in order to minimize the conversion to an open

procedure [16–19] Because the conversion rate in acute

cho-lecystitis is considerably higher compared to elective

proce-dures [20–22], others advocate a two-step procedure with

symptomatic treatment (i.e antibiotics and pain medication)

initially, and 4 to 6 weeks later performing the laparoscopic

cholecystectomy [23–26] This strategy is disadvantaged by

the fact that the patient has to be hospitalized twice with the consequent social and economic cost

In patients undergoing surgery for morbid obesity, cystectomy might be indicated if gallstones are present at the time of surgery, even if symptoms are lacking [27] It is known that women with a body mass index greater than

chole-45 kg/m2have a seven-fold increased risk of developing stones compared to women with a BMI lower than 24 kg/m2

[28] In addition, rapid weight loss is associated with stone formation, thus between 10 and 25% of obese men and women develop gallstones within a few months of beginning

gall-a very low cgall-alorie diet [29] However, less thgall-an 50% of the morbidly obese patients with cholecystolithiasis become symptomatic, and not all of the symptomatic patients require

an operation [30,31] In cases with a normal gallbladder, only

a few centers advocate simultaneous cholecystectomy with a laparoscopic bypass procedure since laparoscopic cholecys-tectomy in morbidly obese patients might be technically difficult, and a lesion of the common bile duct would be catastrophic in these patients, especially when the gallblad-der is normal

Contraindications for laparoscopic cholecystectomy

In patients who suffer from cardiac and pulmonary diseases, and therefore are at an increased risk for general anesthesia, laparoscopic procedures are sometimes not feasible because intra-abdominal pressure might further deteriorate the pa-tient’s condition [32–34] In patients with portal hyperten-sion, the laparoscopic cholecystectomy has to be performed with extreme caution, because any bleeding can turn into a surgical catastrophe, enhanced by concomitant diseases such

as liver dysfunction and coagulopathy Previous open gery in the upper abdomen might also be a contraindication for laparoscopic cholecystectomy, because intra-abdominal adhesions do not allow safe establishment of a pneumoperi-toneum and the dissection of the Calot’s triangle and the gall-bladder might not be possible However, we prefer to start the procedure laparoscopically in all patients with a low thresh-old to convert into an open technique Only if there is a suspi-cion of gallbladder cancer (e.g porcelain gallbladder), we also prefer the primary open procedure

sur-Technique

General anesthesia is preferred for patients undergoing roscopic cholecystectomy If general anesthesia is contrain-dicated (e.g chronic obstructive pulmonary disease), the procedure also can be performed under epidural anesthesia [35,36] There are two different ways to position the patient

lapa-in the operatlapa-ing room: the suplapa-ine position with the surgeon standing on the left and the assisting surgeon holding the camera on the right side of the patient Alternatively, the pa-

Table 9.1 Investigations prior to laparoscopic cholecystectomy.

Blood exams (leucocytes, CRP, bilirubin, alkaline phospatase)

Ultrasound of the abdomen

Only in selected cases

ERCP

MRCP

CT scan

Gastroscopy

176 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

tient is placed in the lithotomy position, where the operating

surgeon stands between the patient’s legs, and the assistant

surgeon is on the left side (Fig 9.1) The supine position is

mainly used in the US, whereas the lithotomy position is very

popular in Europe This led to the expression “American

po-sition” for the first, and “French popo-sition” for the second In

general, an orogastric tube and an indwelling urinary

cathe-ter are not necessary because the operating time of the

proce-dure is usually less than 60 minutes However, in cases with a

distended stomach, an orogastric tube might be useful in

order to get a better exposure of the Calot’s triangle

Pneumoperitoneum can be achieved by two different

techniques A 1-cm incision is made above, below, or in the

umbilical scar to allow the insertion of a Verres needle The

intra-abdominal location is verified by aspiration and then

inserting normal saline solution through the needle Finally,

a drop of saline solution is placed on the top of needle, and

when it is flowing down easily, the needle is in the correct

position Next, a connection to a carbon dioxide insufflator

is established to achieve an intra-abdominal pressure of

15 mmHg This is followed by the insertion of a 10-mm trocar

(optic trocar)

Alternatively, an open or Hasson technique is performed

Using an identical incision, a blunt dissection through the

subcutaneous tissue is carried out in order to reach the

mid-line fascia Next, the fascia and the peritoneum are opened

under direct vision, and a 10-mm Hasson trocar is placed in

the abdominal cavity Pneumoperitoneum is then lished as described above There is no evidence in the litera-ture that the open approach is superior compared to the Verres needle technique in establishing the pneumoperito-neum [37,38] However, in a teaching setting, we prefer the open (Hasson) approach, because we believe that this tech-nique can be better controlled We also recommend the open approach in cases of reinterventions with the danger of intra-abdominal adhesions In contrast, in morbidly obese patients, the open technique may not be easily feasible due to the enormous subcutaneous fat layer, and therefore the Verres needle is preferred

estab-After insertion of a 30° laparoscope, the abdomen is ined for additional pathologies Then, two 5-mm and one 10-

exam-mm trocar are installed under direct vision A grasper is inserted in the most lateral port to elevate the gallbladder fundus above the liver edge while another grasper is passed through the right mid-clavicular port to retract the infundib-ulum in an inferior and lateral direction The dissection be-gins laterally at the infundibulum by opening the serosal layer of the gallbladder Next, the cystic duct is identified and freed from adhesions Then, the cystic artery, that is usually located cranially to the cystic duct, is exposed It is of great importance to keep the Calot’s triangle opened using lateral retraction of the gallbladder infundibulum (Fig 9.2) In gen-eral, it is not necessary to dissect Calot’s triangle out com-pletely, thus it should be avoided to dissect free the CBD,

Figure 9.1 Room setup for laparoscopic cholecystectomy (Adapted from Chirurgische Operationslehre Spezielle Anatomie, Indikationen, Technik,

Komplikationen in 10 Bänden Herausgegeben von K Kremer, W Lierse, W Platzer, H.W Schreiber, S Weller Band 7 Teil 2; Minimal-invasive

Chirurgie Stuttgart: Georg Thieme Verlag, 1995:115.)

Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 177

which forms one side of Calot’s triangle After safe identifi

ca-tion of the cystic duct and cystic artery, two clips are placed

proximally, and one clip distally

One of the most difficult challenges in laparoscopic

chole-cystectomy is a short, wide cystic duct In this situation, clips

usually do not reach across this duct, and even if they do, they

may risk narrowing the CBD (Fig 9.3A) Four acceptable

techniques for closing the wide cystic duct are available If the duct is long and wide, it can be transected and a pretied ligature (an Endoloop) can be applied to the cystic duct stump Alternatively, two ties can be passed around the cystic duct in continuity and secured with extracorporeal knotting techniques When the cystic duct is short and wide, there is concern that this technique might narrow the CBD Under these circumstances, the cystic duct is transected with an en-doscopic stapling device, or it is simply divided and oversewn with an intracorporeal suturing technique (Figs 9.3B and 9.3C) All of these methods have been applied successfully.After the cystic duct, the cystic artery is clipped and divid-

ed Finally, the gallbladder is dissected from its attachments

to the liver, using a hook electrocautery After complete section, the gallbladder is retrieved in a bag via the umbilical port At the end of the procedure, the right upper quadrant is rinsed with saline solution and hemostasis is completed The trocars are retrieved under vision to control bleeding from the trocar sites The fascia at the 10-mm incision is closed with absorbable sutures to prevent port-site hernias

dis-Occasionally, the identifi cation of cystic duct and artery can be very difficult, especially in cases of cholecystitis In these cases, it is helpful to start the dissection of the gallblad-der in an anterograde fashion (i.e from the fundus) in order

to mobilize the whole gallbladder until it is only attached to the cystic duct and artery This technique is called the “dome down” cholecystectomy [39,40]

Complications of laparoscopic cholecystectomy

Complications can occur intra- and postoperatively Bile duct injuries and their management are discussed in depth in a separate chapter

Intraoperative

Bleeding can occur at any time during the procedure It scures anatomical structures and absorbs the light from the

ob-Figure 9.2 The triangle of Calot Dissection of the tissue until the base

of the liver bed is exposed When the triangle of Calot is dissected free,

the two structures entering the gallbladder can only be the cystic duct

and artery It is not necessary to see the common bile duct (Adapted

from Strasberg SM, et al An analysis of the problem of biliary injury

during laparoscopic cholecystectomy J Am Coll Surg

1995;180:101–25.)

Figure 9.3 Techniques for managing a short, wide cystic duct When clips are too short or risk common bile duct (CBD) narrowing (A), the cystic

duct can be closed by endoscopic stapler (B) or a suture (C) (Adapted from Baker RJ and Fischer JE, Mastery of surgery, 4th ed Philadelphia:

Lippincott Williams & Wilkins, 2001.)

178 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

camera Usually, there is adequate time to carefully identify

the source of the bleeding so that precise control can be

complished Because the laparoscope is magnifying, the

ac-tual blood loss is usually quite low Sometimes, it might be

helpful to insert a fifth port site in order to get a better

expo-sure Hemostasis can be achieved with electrocautery (not in

proximity of the CBD!), clips, or simple compression Once,

the bleeding is under control, the hematoma has to be

re-moved completely by suction and irrigation Serious bleeding

can be a sign of injury to the right hepatic artery and should

be regarded as a warning sign, because it can indicate that the

dissection has been performed in the wrong anatomical

plane

Bile spillage occurs in approximately 30% of all

laparo-scopic cholecystectomies [41–43] A thorough irrigation

with saline solution is necessary, whenever bile is lost into

the abdominal cavity Lost stones have to be retrieved

care-fully and completely, although “forgotten” stones have a very

low complication rate, such as intra-abdominal abscess

for-mation (less than 1%) [44,45]

If the gallbladder is enlarged due to severe infl ammation or

hydrops of the gallbladder, a puncture under direct vision is

performed and specimens are taken for microbiology studies

or cultures This maneuver facilitates grasping and holding

of the gallbladder, but has the risk of bile spillage In some

pa-tients, the inflammation of the gallbladder wall leads to dense

adhesions to the liver bed Because the dissection in these

cases may lead to severe bleeding from the liver, it is

some-times advisable to open the gallbladder and just to remove the

“frontwall.” The wall adjacent to the liver is left in place and

extensively coagulated with the electrocautery

Thermal injury can occur from the uncontrolled use of

electrocautery or lasers This may result in ischemic damage

to the duodenal or colonic wall with subsequent perforation

In addition, extensive preparation of the cystic duct and the

ductus choledochus can produce ischemia of the biliary tree,

leading to stenosis and strictures Often this is only

recog-nized months after the initial operation [46]

Postoperative

Bile leaks usually become symptomatic within the first week

after the operation The patient presents with abdominal

pain, fever, and peritonitis Jaundice, nausea, and vomiting

also can occur The main source of bile leak are from the

cys-tic duct (77%), followed by the accessory ducts (15%), and

the common bile duct (8%) [47] Diagnosis is made by

ultra-sound or CT scan, and, if the fl uid collection is large, a

percu-taneous drainage is placed ERCP also may be necessary in

order to demonstrate the presence and the site of leakage

Furthermore, ERCP provides the possibility of adequately

treating bile leaks by placing biliary stents and/or performing

a sphincterotomy Laparoscopic or open surgery is rarely

in-dicated in the treatment of bile leaks and is only advised after

a thorough work-up in order to localize the leakage

An elevation of bilirubin and alkaline phosphatase operatively may indicate a residual stone or damage to the CBD An ERCP is done, where additional stones in the CBD can be easily removed If a lesion of the CBD is diagnosed, open surgery is usually necessary

post-Special techniquesIntraoperative cholangiography

The first intraoperative cholangiography (IOC) was formed by Mirizzi in 1931 [10] In most centers, intra-operative cholangiography became a standard for open cholecystectomy With the development of laparoscopic cholecystectomy, the debate over the indication for intra-operative cholangiography has been renewed Initially, the majority of surgeons were in favor of the routine use of intra-operative cholangiography, because early reports showed a higher incidence of bile duct lesions in laparoscopic cholecys-tectomy compared to open technique It was hypothesized that identifying the anatomy of the biliary tree during the operation would decrease the risk of injury to the CBD How-ever, this has never been proven, and bile duct injuries also occurred when an intraoperative cholangiography was per-formed In addition, intraoperative cholangiography itself has an — albeit minimal — risk of bile duct injury One reason

per-to do intraoperative cholangiography on a routine basis might be the detection of CBD stones (see above)

re-Laparoscopic treatment of the biliary tree

Laparoscopic choledochotomy in order to clear the CBD of stones is rarely indicated and is technically quite a demand-ing procedure With the introduction of laparoscopic cholecystectomy, many surgeons were prompted to develop techniques for removing CBD stones at the time of laparo-scopic cholecystectomy Initially, these techniques were bor-rowed from ERCP and involved the use of baskets passed into the CBD under fluoroscopic guidance A technique from en-dourology that has been valuable is the use of small-caliber flexible endoscopes to retrieve stones Other borrowed

Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 179

techniques from retrograde biliary endoscopy include the

use of balloon dilators and intraoperative sphincterotomy

An algorithm for addressing choledocholithiasis begins with

intraoperative cholangiography or ultrasonography (Fig

9.4) The transcystic (via the cystic duct) approach is

success-ful in over 90% of cases for small stones less than 8 mm in

size, and for stones located below the cystic duct entrance

The transductal approach (via the CBD) is indicated for stones

greater than 8 mm in size, for stones proximal to the insertion

of the cystic duct, and for multiple large stones The

transduc-tal technique should not be performed in a CBD less than

10 mm in diameter as this may lead to postoperative ture We prefer the transcystic approach where possible (over

stric-a trstric-ansductstric-al CBD explorstric-ation) stric-as it hstric-as lower morbidity stric-and shorter length of stay

Common bile duct closure

If the CBD has been explored through the cystic duct, and if the completion cholangiogram demonstrates duodenal fill-

Pass thin caliber

<3.5 mm scope

Endoloop/

clip

Completion of Cholangiogram Duct closure

1 Establish drainage, close

2 Antegrade sphincterotomy

3 Electrohydraulic lithotripsy

4 Convert to open procedure

Fluoroscopic cholangiography or ultrasonography

Distal stone Duct >6 mm Stone(s) 4–8 mm

Impacted stone Proximal stone

Stone(s) >8 mm Multiple large stones CBD >10 mm

Distal stone

Duct <6 mm

Stone(s) <4 mm

Failure (Impacted Stone) Success

Choledochotomy Consider chole- dochoduodenostomy or

Intraoperative sphincterotomy

Dilate cystic duct 5–8 mm (depending

on stone size)

Glucagon 1 mg IV

Flush CBD with saline

Basket under direct vision

Figure 9.4 Management of common bile duct (CBD) stones with laparoscopic cholecystectomy.

180 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

ing, the cystic duct can usually be closed with a single

En-doloop or two clips If spasm, edema, or obstruction of Oddi’s

sphincter is present, a straight latex drain is passed into the

CBD and secured in place with an Endoloop

If a choledochotomy was necessary, a small (No 12 to 14

French) T tube is passed through a 10-mm trocar and placed

in the CBD The CBD can then be closed with two or three

in-terrupted 4-0 monofilament absorbable sutures

Summary

Laparoscopic cholecystectomy has become the standard of

care for the treatment of symptomatic cholelithiasis The

advantages of laparoscopic cholecystectomy over open

cholecystectomy (decreased hospital stay, decreased patient

discomfort, and rapid recovery) are clear With careful,

me-ticulous technique, the complications of this procedure

should be fewer than with open cholecystectomy

Laparo-scopic treatment of the CBD stone is rarely indicated since

pre- or postoperative ERCP is highly successful Only in

se-lected cases, for example in patients with former Roux-en-Y

gastric reconstruction, is time-consuming laparoscopic CBD

exploration justified

Questions

1 Which of the following is not a typical symptom in a patient with

uncomplicated cholecystolithiasis?

a nausea and vomiting

b pain in the upper right abdomen

c jaundice

d pain starts all of a sudden, after a fatty meal

e vague epigastric pain

2 The most important investigation to detect gallstones in the

3 The “Charcot triad” stands for cholangitis and consists of the

following three clinical parameters

a pain, nausea, and fever

b fever, colicky pain, and vomiting

c jaundice, loss of weight, and pain

d painless jaundice, grey stools, and weight loss

e pain, jaundice, and fever

4 How many trocars are inserted for a standard laparoscopic

e depends on the positioning of the patient

5 The best option to treat gallstones in the common bile duct

(CBD) is

a ERCP

b laparoscopic exploration of the CBD

c percutaneous lithotripsy by ultrasound

d extraction of the stones through percutaneous transhepatic drainage (PTCD)

e none of the above

Un-4 Reddick EJ, Olsen DO, Daniel JP, et al Laparoscopic laser cystectomy Laser Med Surg News 1989;7:38–40.

chole-5 Friedman G Natural history of symptomatic and asymptomatic gallstones Am J Surg 1993;165:339–404.

6 Himal HS Common bile duct stones: the role of preoperative, intraoperative, and postoperative ERCP Semin Laparosc Surg 2000;7:237–45.

7 Jansen M, Truong S, Treutner KH, et al Value of intravenous cholangiography prior to laparoscopic cholecystectomy World

J Surg 1999;23:693–6.

8 Röthlin M, Marincek B Intravenous cholangiography is fluous prior to laparoscopic choelaparoscopic cholecystecto- myystectomy Swiss Surg 1997;3:6–8.

super-9 Hammarstrom LE, Holmin T, Stridbeck H, Ihse I Routine operative infusion cholangiography at elective cholecystecto- my: a prospective study in 694 patients Br J Surg 1996;83: 750–4.

pre-10 Mirizzi P Operative cholangiography Surg Gynecol Obstet 1937;65:702–10.

11 Collins C, Maguire D, Ireland A, et al A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisit-

ed Ann Surg 2004;239:28–33.

12 Metcalfe MS, Ong T, Bruenning MH, et al Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004;187:475–81.

13 Romano F, Franciosi CM, Caprotti R, et al Preoperative tive endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy without cholangiography Surg Laparosc Endosc Percutan Tech 2002;12:408–11.

selec-14 Bittner R The standard of laparoscopic cholecystectomy genbecks Arch Surg 2004;389:157–63.

Lan-Chapter 9: Laparoscopic treatment for diseases of the gallbladder and biliary tree 181

15 Barwood NT, Valinsky LJ, Hobbs MS, et al Changing methods

of imaging the common bile duct in the laparoscopic

cholecys-tectomy era in Western Australia: implications for surgical

practice Ann Surg 2002;235:41–50.

16 Johansson M, Thune A, Blomqvist A, et al Management of

acute cholecystitis in the laparoscopic era: results of a

prospec-tive, randomized clinical trial J Gastrointest Surg 2003;7:

642–5.

17 Madan AK, Aliabadi-Wahle S, Tesi D, et al How early is early

laparoscopic treatment of acute cholecystitis? Am J Surg 2002;

183:232–6.

18 Uchiyama K, Onishi H, Tani M, et al Timing of laparoscopic

cholecystectomy for acute cholecystitis with

cholecystolithia-sis Hepatogastroenterology 2004;51:346–8.

19 Cheema S, Brannigan AE, Johnson S, et al Timing of

laparo-scopic cholecystectomy in acute cholecystitis Ir J Med Sci

2003;172:128–31.

20 Kanaan SA, Murayama KM, Merriam LT, et al Risk factors for

conversion of laparoscopic to open cholecystectomy J Surg Res

2002;106:20–4.

21 Bender JS, Duncan MD, Freeswick PD, et al Increased

laparo-scopic experience does not lead to improved results with acute

cholecystitis Am J Surg 2002;184:591–4.

22 Bingener-Casey J, Richards ML, Strodel WE, et al Reasons for

conversion from laparoscopic to open cholecystectomy: a

10-year review J Gastrointest Surg 2002;6:800–5.

23 Cameron IC, Chadwick C, Phillips J, Johnson AG Acute

chole-cystitis — room for improvement? Ann R Coll Surg Engl 2002;

84:10–13.

24 Schäfer M, Krähenbühl L, Büchler MW Predictive Factors for

the type of surgery in acute cholecystitis Am J Surg

2001;182:291–7.

25 Cameron IC, Chadwick C, Phillips J, Johnson AG Management

of acute cholecystitis in UK hospitals: time for a change

Post-grad Med J 2004;80:292–4.

26 Johansson M, Thune A, Blomquvist A, et al Impact of choice of

therapeutic strategy for acute cholecystitis on patient’s

health-related quality of life Results of a randomized, controlled study

Dig Surg 2004;21:359–62.

27 Hamad GG, Ikramuddin S, Gourash WF, Schauer PR Elective

cholecystectomy during laparoscopic Roux-en-Y gastric bypass:

is it worth the wait? Obes Surg 2003;13:76–81.

28 Stampfer MJ, Maclure KM, Colditz GA, et al Risk of

symptom-atic gallstones in women with severe obesity Am J Clin Nutr

1992;55:652–8.

29 Everhart JE Contributions of obesity and weight loss to

gall-stone disease Ann Intern Med 1993;119:1029–35.

30 Amaral JF, Thompson WR Gallbladder disease in the morbidly

obese Am J Surg 1985;149:551–7.

31 Shiffman ML, Sugerman HJ, Kellum JM, et al Gallstone

forma-tion after rapid weight loss: a prospective study in patients

un-dergoing gastric bypass surgery for treatment of morbid obesity

Am J Gastroenterol 1991;86:1000–5.

32 Stuttmann R, Vogt C, Eypasch E, Doehn M Haemodynamic changes during laparoscopic cholecystectomy in the high-risk patient Endosc Surg Allied Technol 1995;3:174–9.

33 Thoelke MH, Merkelbach D, Ehmann T, et al The abdominal lift: is there any advantage for the critically ill patient? Endosc Surg Allied Technol 1995;3:180–2.

34 Schulte Steinberg H, Euchner-Wamser I, Zalunardo MP thesia for laparoscopic procedures Anaesthesist 1999;48: 755–68.

Anes-35 Gramatica L Jr, Brasesco OE, Mercado Luna A, et al scopic cholecystectomy performed under regional anethesia in patients with chronic obstructive pulmonary disease Surg En- dosc 2002;16:472–5.

Laparo-36 Pursnani KG, Bazza Y, Calleja M, Mughal MM Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease Surg Endosc 1998;12:1082–4.

37 Byron JW, Markenson G, Miyazawa K A randomized son of Verres needle and direct trocar insertion for laparoscopy Surg Gynecol Obstet 1993;177:259–62.

compari-38 Schafer M, Lauper M, Krahenbuhl L Trocar and Veress needle injuries during laparoscopy Surg Endosc 2001;15:275–80.

39 Rosenberg J, Leinskold T Dome down laparoscopic tomy Scand J Surg 2004;93:48–51.

cholecystec-40 Fullum TM, Kim S, Dan D, Turner PL Laparoscopic down” cholecystectomy with the LCS-5 Harmonic scalpel J Soc Laparoendosc Surg 2005;9:51–7.

“dome-41 Assaff Y, Matter I, Saba E, et al Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder per- foration, bile spillage, and “loss” of stones Eur J Surg 1998; 164:425–31.

42 Kirnura T, Gote H, Takeuchi Y, et al Intraabdominal tamination after gallbladder perforation during laparoscopic cholecystectomy and its complications Surg Endosc 1996;10: 888–91.

con-43 Soper NJ, Dunnegan DL Does intraoperative gallbladder ration influence the early outcome of laparoscopic cholecystec- tomy? Surg Laparosc Endos 1991;1:156–61.

perfo-44 Memon MA, Deeik RK, Maffi TR, et al The outcome of trieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy A prospective analysis Surg Endosc 1999;13: 848–57.

unre-45 Schaefer M, Suter C, Klaiber C, et al Spilled gallstones after aroscopic cholecystectomy A relevant problem? A retrospec- tive analysis of 10,174 laparoscopic cholecystectomies Surg Endosc 1998;12:305–9.

lap-46 Davido FE, Pappas TN, Murray EA, et al Mechanism of major biliary injury during laparoscopic cholecystectomy Ann Surg 1992;215:196–202.

47 Barkun AN, Rezieg M, Mehta SN, et al Post-cholecystectomy leaks in the laparoscopic era: risk factors, presentation and management Gastrointest Endosc 1997;45:277–83.

C H A P T E R 10 Laparoscopic biliary injuries

Steven M Strasberg

10

O B J E C T I V E S

• Be able to classify biliary injuries

• Understand the cause of misidentification injuries and their avoidance

• Understand the cause of technical errors and their avoidance

• Conduct investigations of biliary injuries

• Be familiar with techniques of repair of biliary injuries

• Be knowledgeable about the results of treatment of biliary injuries

Introduction

Biliary injury is the most severe common complication of

cholecystectomy It is always morbid, occasionally fatal,

in-creases cost [1–3], and often results in litigation [4–6] Bile

duct injury has always been a risk of cholecystectomy but its

incidence increased sharply when laparoscopic surgery for

cholecystolithiasis was introduced Not only has laparoscopic

cholecystectomy led to more injuries, but certain types of

in-jury, such as ductal lacerations, bile leaks, and aberrant duct

injuries, are more common than they were previously The

causes of injury are becoming better understood and

im-proved methods for preventing injury are available When

injury occurs, a high rate of permanent cure is possible using

advanced techniques of reconstruction in specialized

centers

Classification of biliary injuries

Bismuth classified benign biliary strictures into five types

based on the upper level of the stricture This classifi cation

was used to stratify biliary injuries in the era of open

chole-cystectomy, but it became somewhat less useful as the injury

pattern altered due to laparoscopic cholecystectomy [7–15]

In 1995, we introduced a classifi cation that retained the

essence of the Bismuth classifi cation for major injuries, but

broadened the classifi cation to separately itemize injuries

seen with increased frequency during laparoscopic

cholecys-tectomy [16] and this classifi cation has found considerable

acceptance [17–23] Other classifi cation schemes not based

on the Bismuth classifi cation have been proposed by

se-is little chance of progression to a more serious form of injury However, even these injuries can be quite morbid They are usually lateral injuries to the biliary tract and therefore de-creasing intrabiliary pressure by endoscopic sphincterotomy results in healing

Types B and C: creation of a discontinuity of part

of the biliary tree with occlusion (type B) or intraperitoneal leak (type C)

These are end injuries which isolate a part of the biliary tree They almost always result from injury to an aberrant right hepatic duct, although rarely an aberrant left ducts or a nor-mally situated duct may be involved For instance a com-pletely occluded or transected right hepatic duct would be classified here About 2% of patients have an aberrant low-lying right duct which most commonly drains one or two segments of the right hemiliver [27] A key anatomical fea-ture contributing to the likelihood of injury is that in some cases the cystic duct joins the aberrant duct, which then con-tinues to join the main ductal system The appearance of the

Diseases of the Gallbladder and Bile Ducts: Diagnosis and Treatment, Second Edition

Edited By Pierre-Alain Clavien, John Baillie Copyright © 2006 by Blackwell Publishing Ltd

Chapter 10: Laparoscopic biliary injuries 183

termed type C (Fig 10.1) The reason for the difference in classifi cation is that presentation, management, and often prognosis are very different Occlusions are generally inju-ries of lesser severity They are often asymptomatic, or if symptomatic may not cause symptoms such as cholangitis for months or years (Fig 10.3) The liver upstream from a type B injury atrophies and the remaining liver undergoes compen-satory hyperplasia Transections without occlusion (type C) result in local intraperitoneal bile collections or bilious asci-tes and peritonitis Type C injuries usually present in the early postoperative period and almost always require treatment (Fig 10.4)

In the Bismuth classifi cation, B injuries were lumped under the heading type 5, along with combined injuries of the common hepatic duct and an aberrant duct Because isolated aberrant duct injuries are so much more common in the laparoscopic era they were separated out in our classifi cation

Type D: lateral injury to major bile ducts

D injuries are partial (<50%) transections of major bile ducts When the transection involves more than 50% of the cir-cumference of the duct, the injury should be considered an E type Like the type A variant, they are lateral injuries and will often resolve after decompression by postoperative endoscopic sphincterotomy Or if discovered at the time

of surgery they may be corrected by simple suturing niques and the placement of a t-tube Type D injuries have the potential to evolve into more serious injuries, particular-

tech-ly if they are of thermal causation or associated with scularization of the bile duct Then they may progress to complete obstruction, that is a type E injury Type D injuries may occur to other major ducts Right hepatic duct injuries similar to that shown in Fig 10.5 have been reported [12,14] Type C and type D injuries involving the right bile duct are very similar, but there are major therapeutic impli-cations to complete transection (type C) versus lateral injury (type D)

deva-Inadvertent incision of the common bile duct instead of the cystic duct, when attempting to delineate ductal anatomy by operative cholangiography might be considered to be a type

D injury Provided the only consequence is that a T-tube is placed in the common bile duct without later consequences, such as bile duct stricture or leakage, we do not consider this

to be a biliary injury Cannulation of the bile duct, in order to protect it during abdominal surgery, is an accepted proce-dure and is not in itself considered a complication

Type E: circumferential injury of major bile ducts (Bismuth class 1–5)

These are circumferential injuries of major bile ducts As noted above, Bismuth’s classifi cation was one of strictures, which has been applied by many authors to biliary injuries, whether strictures or transections Subclassifi cation into

Figure 10.1 A classification of laparoscopic injuries to the biliary tract

Injury types A to E are illustrated Type E injuries are subdivided

according to the Bismuth classification Type A injuries originate from

small bile ducts that are entered in the liver bed or from the cystic duct

Type B and C injuries almost always involve aberrant right hepatic ducts

The notations >2 cm and <2 cm in type E1 and type E2 indicate the

length of common hepatic duct remaining (Reproduced from Strasberg

SM, Hertl M, Soper NJ An analysis of the problem of biliary injury during

laparoscopic cholecystectomy J Am Coll Surg 1995;180:101–25 with

permission from the Journal of the American College of Surgeons.)

junction of the aberrant duct with the hepatic duct may be

identical to that of the junction of the cystic duct with the

hepatic duct As a result there is great potential for injury

in these circumstances

When the injury is a ductal occlusion it is designated type B

(Fig 10.1) When it is a transection without occlusion it is

184 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

types E1 to E4 is based on the level of injury (Figs 10.6 and

10.7), while type E5 is a combination of common hepatic duct

and aberrant right duct injury (Fig 10.8) Type E injuries

separate the hepatic parenchyma from the lower biliary tract,

due to stenosis, simple occlusion, or transection When

oc-clusions or transections are present, resection of bile ducts

may also have occurred To classify the injury properly it

must be stated which of these is present and if bile duct

resec-tion has occurred the length of excised duct should be given,

for example “E2, simple total occlusion without resection” or

“E3, 3-cm duct length excised, transection without proximal

occlusion, distal occlusion present.” For purposes of repair

the upper limit of injury is the key variable and this is given in

the E type itself

The incidence of laparoscopic biliary injury

An increase in biliary injuries was an unforeseen

accompa-niment of laparoscopic cholecystectomy The first indication

of the problem was a sudden surge of referrals of biliary

injuries to specialized hepatopancreaticobiliary units To

determine the true incidence of injury, large, accurate, representative studies were needed Institutional or multi-institutional studies, studies of fewer than several thousand cases, and studies with less than 100% reporting including mail surveys, fail to satisfy these conditions

Several excellent reports exist, including statewide ations from New York and Connecticut [28–30], a report from the armed services [31], and several from Europe [18,32–34] In all reports, an increase in the injury rate from 0.1% in the open era to 0.3 to 0.5% in the early laparoscopic era was noted It is encouraging that two studies found that the injury rate is decreasing towards that in the open chole-cystectomy era [30,33] All the early reports encompassed the period during which most surgeons were learning to per-form the operation As injury is more likely during the per-formance of the first fifty cholecystectomies, the injury rates reported in these studies are probably higher than current rates Unfortunately, no study using reliable population tech-niques has defined the incidence in this decade and therefore

evalu-it cannot be definevalu-itively stated whether injury rates remain above those before the introduction of laparoscopic cholecys-

Figure 10.2 ERCP in a patient who developed a biloma Note that the injury is to a small branch of a hepatic duct The arrow points to the beginning

of the contrast leak from the small duct Sphincterotomy resolved the problem (Reproduced from Strasberg SM, Hertl M, Soper NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy J Am Coll Surg 1995;180:101–25 with permission from the Journal of the American College of Surgeons.)

Chapter 10: Laparoscopic biliary injuries 185

Figure 10.3 (A) A postoperative ERCP

demonstrating a type B injury Note absence of right

posterior sectional ducts (segments 6 and 7) (B)

Another type B injury involving the whole right side

of the liver This patient complained of heaviness in

the upper right quadrant beginning several months

after cholecystectomy and required reconstruction

(Reproduced from Strasberg SM, Hertl M, Soper NJ

An analysis of the problem of biliary injury during

laparoscopic cholecystectomy J Am Coll Surg

1995;180:101–25 with permission from the Journal

of the American College of Surgeons.)

(A)

(B)

186 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

Figure 10.4 A percutaneous cholangiogram in a

patient with a type C injury A segment of the right posterior sectional duct had been excised and a postoperative biloma resulted Note the percutaneous stent used to drain biloma and guide surgical repair (Reproduced from Strasberg SM, Hertl M, Soper NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy J

Am Coll Surg 1995;180:101–25 with permission from the Journal of the American College of Surgeons.)

Figure 10.5 Type D injury to the right hepatic

duct–common hepatic duct junction A T-tube is in place Note the dye extravasation (Reproduced from Strasberg SM, Hertl M, Soper NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy J Am Coll Surg 1995;180:101–25 with permission from the Journal of the American College of Surgeons.)

Chapter 10: Laparoscopic biliary injuries 187

Figure 10.6 Type E2 injury with a stenosis just

below the bifurcation of the hepatic ducts.

tectomy However, based on available evidence, it seems that

the incidence of the more serious type E injuries are moving

towards rates seen in the open era but that type A to D

inju-ries, which were rarely seen in the open era, are still more

common today

Risk factors for biliary injury

Training and experience

Early reports suggested that the high rate of injury was due

mainly to inexperience in the procedure referred to as the

“learning curve effect” [35,36] Unquestionably, experience

did initially contribute to the high incidence of injury, but

other factors are responsible for injury today

Local operative risk factors

As during open cholecystectomy, biliary injuries seem more

likely to occur during difficult laparoscopic

cholecystecto-mies [26,30,37] Russell, in a very large registry series from

the State of Connecticut, reports that the incidence of injury

when laparoscopic cholecystectomy is performed for acute

cholecystitis (0.51%) is three time higher than that for tive laparoscopic cholecystectomy and twice as high as open cholecystectomy for acute cholecystitis [30] Thousand of pa-tients are required to see this difference [26,30], and one should be wary of concluding that the procedure is as safe as elective cholecystectomy based on reports of a few hundred patients Chronic infl ammation with dense scarring [18], operative bleeding obscuring the field, or fat in the portal area are cited as contributing factors in 15 to 35% of injuries [6,8,9,14] Blood in the field hampers dissection more in lap-aroscopic than in open cholecystectomy, and gentle dissec-tion is required, especially when infl ammation is present, to avoid bleeding that then obscures vision [6,38,39] The role

elec-of obesity is difficult to evaluate, since it is so elec-often present in patients with cholelithiasis

Aberrant anatomy

Aberrant anatomy is a well-described danger in biliary gery The aberrant right hepatic duct anomaly, referred to above under type B and type C injuries, is the most common anomaly associated with biliary injury There are several

sur-188 Section 2: Diagnostic and therapeutic approaches for the biliary tree and gallbladder

Figure 10.7 An E4 injury in which the right hepatic duct (left panel) and the left hepatic duct (right panel) have been isolated by resection of the

bifurcation of the hepatic ducts This percutaneous cholangiogram preceded the placement of stents immediately prior to surgery.

Figure 10.8 E5 injury treated at the time of

laparoscopic cholecystectomy by a double barreled choledochocholedochotomy and splinted with a T- tube (arrow), whose upper limb was divided and placed in the common hepatic duct and the aberrant right duct These anastomoses strictured (Reproduced from Strasberg SM, Hertl M, Soper NJ

An analysis of the problem of biliary injury during laparoscopic cholecystectomy J Am Coll Surg 1995;180:101–25 with permission from the Journal

of the American College of Surgeons.)

Chapter 10: Laparoscopic biliary injuries 189

reports of injury to aberrant right hepatic ducts during

laparoscopic cholecystectomy [6,8,12,14,40,41] These

injuries are probably under-reported since type B injuries

may be asymptomatic (Fig 10.3) [42] Isolated injuries to

aberrant right ducts did occur before the advent of

laparo-scopic cholecystectomy, but such ducts appear to be

particu-larly prone to injury during laparoscopic cholecystectomy

[16]

Equipment

Laparoscopic equipment must be well maintained Thermal

injuries to bile ducts or surrounding structures [43] may

occur due to focal loss of insulation on instruments used for

cauterization Also a charge may build up on laparoscopic

in-struments and cause arcing to surrounding structures The

incidence of such events must be extremely low, but specially

shielded laparoscopic equipment and detectors are slowly

be-coming available to deal with the problem, although their

use is not widespread

Direct causes of laparoscopic biliary injury

Biliary injury occurs either due to anatomical misidentifi tion of the cystic duct or due to technical problems, especially the misuse of cautery

ca-Misidentification injuries

Misidentifi cation is the most common cause of serious ries There are two scenarios In the first, the common duct is mistaken for the cystic duct, and is clipped and divided (Fig 10.9A, point x) To complete the excision of the gallbladder the bile ducts must be divided again The type of injury pro-duced varies from E1 to E4 and depends on the level of the second division of the biliary tree (Fig 10.9A, point y1or y2) Frequently, a “second cystic duct” or “accessory duct,” which

inju-is actually the common hepatic duct, inju-is reported in the tive notes of these procedures, but just as often the second transection is not noted High transections are probably asso-ciated with excessive traction on the gallbladder, an act which

opera-Figure 10.9 Patterns of biliary injury due to misidentification (A) The

“classic” type E injury in which the common duct is divided between

clips at point x The ductal system is later divided again to remove the

gallbladder either at point y1, producing E1 or E2 injuries, or at point y2,

producing E3 or E4 injuries (B) Variant of type E injury (C) Variant of

type E injury leading to clipping but not excision of the duct This injury

also causes intraoperative bile leakage, except when cystic and common

bile ducts are both occluded, as shown in the inset (D–F) Variants of

injury to aberrant right hepatic duct, producing type B or type C injuries The injuries shown in D, E, and F correspond to the injuries shown in A, B, and C but affect the aberrant right duct (Reproduced from Strasberg

SM, Hertl M, Soper NJ An analysis of the problem of biliary injury during laparoscopic cholecystectomy J Am Coll Surg 1995;180:101–25 with permission from the Journal of the American College of Surgeons.)