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Unique Identifier 97337550
Author Fruhwirth J; Koch G; Mischinger HJ; Werkgartner G; Tesch NP
Institution Department of Vascular Surgery, Karl Franzens University Graz, Austria.
Title Vascular complications in minimally invasive surgery.
Source Surg Laparosc Endosc 1997 Jun;7(3): p251-4
ISSN 1051-7200
AbstractInjuries to major vessels in the course of laparoscopic surgery are rare but serious, life-threatening complications. We report nine iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and December 1995 in surgical and obstetric-gynecologic services in the Austrian province of Styria. The total vascular complication rate is 0.08%. As these data show, the distal abdominal aorta and vena cava, as well as the large pelvic vessels, are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these eight arterial lesions required a polytetrafluorethylene (PTFE) patch in one case, and the resection of the damaged section of the artery and reanastomosis in two others. The remaining lesions, as well as an isolated vein injury, were corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients, and permanent damage was avoided.Unique Identifier 99443563
Author Hui TT; Giurgiu DI; Margulies DR; Takagi S; Iida A; Phillips EH
Institution Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Title Iatrogenic gallbladder perforation during laparoscopic cholecystectomy: etiology and sequelae.
Source Am Surg 1999 Oct;65(10): p944-8
ISSN 0003-1348
AbstractIatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.Unique Identifier 98219418
Author Carroll BJ; Birth M; Phillips EH
Institution Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
Title Common bile duct injuries during laparoscopic cholecystectomy that result in litigation.
Source Surg Endosc 1998 Apr;12(4): p310-3; discussion 314
ISSN 0930-2794
AbstractBACKGROUND: Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries.
METHODS: A total of 46 bile duct injuries were analyzed by review of medical records, cholangiograms, videotapes, and surgeon statements. All cases were involved in malpractice litigation.
RESULTS: All types of injuries were represented. There were 15 transections, 11 excisions, 6 lacerations, 8 clip impingements, 3 burns, 2 bile leaks, and 1 cystic duct leak. In all, 72% of these injuries occurred in elective cases in which there was no acute inflammation. Cholangiograms were performed in 16 cases, but they were misinterpreted in 11 of them. Injury type and severity was similar in patients with and without cholangiography. A total of 80% of these injuries were not detected at the initial surgery. The average delay in diagnosis was 10 days. Complications were worse in patients with delayed diagnosis. Primary surgeons had less successful outcomes from repairs than referral surgeons (27% versus 79%). In 86% of cases, litigation was resolved in favor of plaintiffs by settlement or verdicts. The average award was $214,000.
CONCLUSIONS: Factors that predispose to lawsuits include treatment failures in immediately recognized injuries, complications that result from delays in diagnosis, and misinterpretation of abnormal cholangiograms. Injury prevention can be improved by increased awareness of common mistakes,. Improved cholangiographic technique and interpretation should decrease injury severity, delays in diagnosis, and subsequent morbidity.Unique Identifier 98291030
Author Taylor B
Institution Department of Surgery, University of Toronto, Ont.
Title Common bile duct injury during laparoscopic cholecystectomy in Ontario: does ICD-9 coding indicate true incidence? [see comments]
Source CMAJ 1998 Feb 24;158(4): p481-5
ISSN 0820-3946
AbstractBACKGROUND: Recent reports in the scientific and lay press have suggested that bile duct injuries during laparoscopic cholecystectomy are common in Ontario. The reports were based on administrative data collected by hospital medical records departments and the Canadian Institute for Health Information (CIHI). The current study involved a direct inspection of hospital records to determine if the CIHI data accurately captured the rate of clinically significant bile duct complications.
METHODS: For the period 1991 to 1995, records of bile duct injuries after laparoscopic cholecystectomy were independently evaluated to clarify the clinical significance of the complications. Of 21 Ontario hospitals for which data on complications had been reported in the media, 18 provided detailed information on all patients reported to have suffered bile duct complications classified by the hospital as "major". In addition, each institution provided information on a random sample of one-sixth of the patients who had suffered complications classified as "minor". The reviewer then examined each relevant hospital chart to assess the grade and significance of the reported complications.
RESULTS: All 24 bile duct injuries classified by the hospitals as "major" were confirmed as major (clinically relevant) injuries. Of the 80 bile duct complications classified by the hospitals as "minor", 76 (95%) were irrelevant to patient outcome. The discrepancy between data collected and reported frequency of injury lies in the use of nonspecific coding methods.
INTERPRETATION: The rate of significant bile duct injuries cannot be inferred from nonspecific codes taken from the International Classification of Diseases, ninth revision, and presented in hospital discharge records. Therefore, such data must be interpreted with extreme caution.Unique Identifier 97477098
Author Kwon AH; Uetsuji S; Ogura T; Kamiyama Y
Institution First Department of Surgery, Kansai Medical University, Moriguchi, Osaka, Japan.
Title Spiral computed tomography scanning after intravenous infusion cholangiography for biliary duct anomalies.
Source Am J Surg 1997 Oct;174(4): p396-401; discussion 401-2
ISSN 0002-9610
AbstractBACKGROUND: Iatrogenic injury of the bile duct during cholecystectomy represents a failure of surgical technique, especially for laparoscopic surgery. Knowledge of the patient's individual ductal anatomy and anomalies preoperatively would be helpful in avoiding such injuries. Therefore, we investigated the anatomy of the biliary duct and any anomalies using spiral computed tomography (SCT) scanning following intravenous infusion cholangiography (IVC-SCT).
MATERIALS: Laparoscopic cholecystectomies (LC) were attempted on 437 patients at the Kansai Medical University. Preoperative IVC-SCT and laparoscopic cholangiography were attempted in all of the patients.
RESULTS: An overall anomalous union of the cystic duct was seen in 71 (16.2%) out of the 437 patients subjected to IVC-SCT. The following anomalies were observed: right hepatic duct entry in 7 cases (1.6%), parallel low entry in 17 cases (3.9%), posterior spiral entry in 35 cases (8.0%), anterior spiral entry in 7 cases (1.6%), and accessory duct entry in 5 cases (1.1%). The success rate for the LC was 99.5% (435/437). Three patients were switched to open surgery owing to advanced gallbladder cancer and severe adhesions. The success rate for the laparoscopic cholangiography was 97.2% (423 of 435). Intraoperative right hepatic duct injury occurred in only 1 patient with a bile duct anomaly, and it was repaired with laparoscopic T-tube drainage.
CONCLUSIONS: The preoperative examination of the biliary tract by IVC-SCT was technically simple, less invasive, and may helpful in avoiding damage to the bile duct, especially in patients with biliary duct anomalies.Unique Identifier 99086324
Author Vecchio R; MacFadyen BV; Latteri S
Institution Department of Surgery, University of Catania, Italy.
Title Laparoscopic cholecystectomy: an analysis on 114,005 cases of United States series.
Source Int Surg 1998 Jul-Sep;83(3): p215-9
ISSN 0020-8868
Abstract114,005 cases from 40 United States series of laparoscopic cholecystectomies (LC) were reviewed. Indications, conversion rates, rates of intra-operative cholangiography (IOC), and incidence of bile duct stone and iatrogenic bile duct injuries were assessed. Indications included acute cholecystitis in 11.6% and gallstone pancreatitis in 2.1% of reported cases. Conversion rate was to be primarily related to inflammation. Unsuspected bile duct stones were detected intra-operatively in 7.8% of cases. 561 major bile duct injuries (BDI) and 401 bile leaks (BL) were recorded and acute or chronic inflammation was their most important potential predisposing factor. In series with a high rate of IOC performed during LC, BDI and BL were slightly lower and lesions recognized intra-operatively were much higher than in series with low rate of IOC. BDI occurred in the first 50 patients of the surgeon's experience in about 91% of the cases.Unique Identifier 98222910
Author Windsor JA; Pong J
Institution Surgical Skills Training Centre, Department of Surgery, Faculty of Medicine and Health Science, University of Auckland, New Zealand. j.windsor@auckland.ac.nz.
Title Laparoscopic biliary injury: more than a learning curve problem.
Source Aust N Z J Surg 1998 Mar;68(3): p186-9
ISSN 0004-8682
AbstractBACKGROUND: The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC.
METHODS: A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n=184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) (n=18, response rate 100%).
RESULTS: The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%).
CONCLUSIONS: The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.Unique Identifier 98259098
Author Vecchio R; MacFadyen BV; Ricardo AE
Institution University of Catania, Catania, Italy.
Title Bile duct injury: management options during and after gallbladder surgery.
Source Semin Laparosc Surg 1998 Jun;5(2): p135-44
ISSN 1071-5517
AbstractProper management of iatrogenic bile duct injuries is mandatory to avoid immediate or late life threatening sequelae. Results of surgery depend mainly on the type of injury, the detection of the injury, and the timing of the surgery. Lesions detected during cholecystectomy should be repaired immediately, preferably with an end-to-side biliary anastomosis, a Roux-en-Y bilio-enteric anastomosis, or by the insertion of a T-tube. Bile duct injuries detected in the postoperative phase require a multidisciplinary approach and an algorithm for treatment of each type of lesion is proposed. In bile peritonitis with biliary obstruction and/or transection and in tight long strictures, which develop several months after cholecystectomy, a Roux-en-Y hepatico-jejunostomy is the most commonly performed operation. Other surgical techniques include a "mucosal graft" procedure and intrahepatic biliary enteric anastomoses, which may be required in difficult high-biliary lesions. Endoscopy and/or interventional radiology offer the best treatment options in bile duct leaks and in short ductal strictures that involve less than 50% of the bile duct lumen. In these injuries, surgical management should be performed only in the failure of nonsurgical methods. Because these lesions involve complicated biliary surgery, therapeutic endoscopy, and interventional radiology, treatment should be performed where there is expertise in all three areas. Copyright 1998 W.B. Saunders Company.Unique Identifier 20265557
Author Lee CM; Stewart L; Way LW
Institution Department of Surgery, University of California, San Francisco, USA.
Title Postcholecystectomy abdominal bile collections.
Source Arch Surg 2000 May;135(5): p538-42; discussion 542-4
ISSN 0004-0010
AbstractHYPOTHESIS: The clinical syndromes caused by bile collections in the abdomen span a wide spectrum and their natural history and risks are not fully appreciated.
DESIGN: Analysis of 179 patients with bile fistulas after cholecystectomy, of which 154 patients had undrained bile collections.
OBJECTIVE: To characterize the manifestations and natural history of abdominal bile collections.
SETTING: A tertiary care teaching hospital.
PATIENTS AND METHODS: The clinical findings in 179 patients with bile fistulas resulting from iatrogenic laparoscopic bile duct injuries and other miscellaneous operations between 1990 and 1999 were analyzed. The group of main interest consisted of 154 patients with undrained bile collections. Of these 154 patients, 21% had serious complications, including sepsis and multiorgan failure. The data were analyzed to identify the variables associated with this undesirable outcome.
MAIN OUTCOME MEASURES: Symptoms, physical findings, course of illness, and laboratory and imaging findings.
RESULTS: The clinical manifestations of intra-abdominal bile collections were initially discounted in 77% of patients, so the problem went unsuspected for a variable and often lengthy period. Abdominal pain and tenderness (bile peritonitis) gradually developed in 18% of patients with bile ascites. There were no differences in the initial clinical findings in this group compared with those who did not develop peritonitis. Nineteen percent of patients with undrained bile collections experienced serious morbidity. The initial clinical findings did not differ in these patients compared with those with a less complicated illness. Serious illness, however, was associated with the following: (1) a longer period of undrained bile (15.4 vs 9.2 days, P=.04) and (2) a higher incidence of infected bile (45% vs 7%, P=.001).
CONCLUSIONS: (1) Prominent abdominal pain and tenderness developed in only 21% of patients with abdominal bile collections; (2) the symptoms caused by bile collections were often subtle and their significance was overlooked, which resulted in a delay in diagnosis; (3) the early clinical findings could not distinguish patients who did become critically ill from those who did not; and (4) seriously ill patients more often had delayed drainage and infected bile. Still, failure to drain a bile collection within just 5 days resulted in serious illness in a few patients. Surgeons must watch for the clinical manifestations of bile ascites after laparoscopic cholecystectomy. This diagnosis should be suspected whenever persistent bloating and anorexia last for more than a few days; failure to recover as smoothly as expected is the most common early symptom of bile ascites. If bile collections were promptly diagnosed and drained, the rate of serious illness resulting from this complication would decline.Unique Identifier 97175836
Author Carroll BJ; Friedman RL; Liberman MA; Phillips EH
Institution Division of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 795W, Los Angeles, CA 90048, USA.
Title Routine cholangiography reduces sequelae of common bile duct injuries.
Source Surg Endosc 1996 Dec;10(12): p1194-7
ISSN 0930-2794
AbstractBACKGROUND: An effort was made to determine whether a policy of routine cholangiography affects the incidence, morbidity, and cost of bile duct injuries.
METHODS: A retrospective review of consecutive 3,242 laparoscopic cholecystectomies was performed. Most patients had routine intraoperative cholangiography.
RESULTS: There were 12 bile duct injuries (0.37%). All injuries were Bismuth levels 1 and 2. Eleven of 12 injuries were recognized intraoperatively. Ten were repaired primarily and one required hepaticojejunostomy. All repairs were successful. Average hospital charges were $26,669. One of 12 patients had delayed recognition of a bile duct injury and underwent primary repair over a T-tube on postoperative day 7. Hospital charges were $43,957.
CONCLUSION: Routine cholangiography did not appear to decrease the absolute incidence of bile duct injuries compared to previously published reports. Injury severity, morbidity, late sequelae, and costs were reduced by a policy of routine cholangiography.
