Iatrogenic extrahepatic bile duct injury: Prevention is better than repair

Abstract

In the 6 year period, between 1994-1999, 40 patients with extrahepatic bile duct injury caused during open cholecystectomy (OC) (35 patients) and laparoscopic cholecystectomy (LC) (5 patients), were referred to one surgical unit from either the University Hospital, Banaras Hindu University (3 patients) or nursing homes (37 patients). These patients were studied with the aim to assess the cause, evaluate the treatment and suggest measures of prevention. Injury to the common bile duct (CBD) was present in 24 patients, common hepatic duct (CHD) in 16 patients and in one patient the accessory cystic duct was injured. In 14 patients the injury was detected during operation. No attempt to repair was made in 4 and an unsuccessful attempt of primary repair was made in 10 patients by the operating surgeon. The skin incision was inadequate, measuring less than 8 cms in 10 patients. Patients presented with bile fistula in 24, obstructive jaundice in 13 patients, peritonitis in 2 and ascites in 1 patient. Further ascites with fistula and obstructive jaundice was present in 3 and 1 patient respectively. Two patients with biliary peritonitis with fistula died and one more patient died after Roux-en-Y choledocho-duodenostomy. In one patient bile fistula closed spontaneously. A variety of bypass procedures were used in the remaining pateints including choledocho-duodenostomy in 6, hepatico-duodenostomy in 3 and Roux-en-Y choledocho-jejunostomy in 20 patients. Six to eighty (median 15) months follow-up has shown stricture formation in one patient who underwent choledocho-duodenostomy and one with repair of CBD on a T-tube. Eight (20%) patients continue to complain of dyspeptic symptoms. In conclusion 1. Extrahepatic bile duct injury occurs in a proportion of patients undergoing cholecystectomy. 2. On detection of the injury during operation the inexperienced surgeon should not make any attempt at primary repair. 3. Roux-en-Y choledocho/hepaticoenteric anastomosis is an adequate method of repair. Further research on the overall prevalence and the causes of iatrogenic injury to the extrahepatic biliary tree is indicated with the participation of all surgeons carrying out the procedure of cholecystectomy.