LAPAROSCOPIC CHOLECYSTECTOMY

In a series of 68 cases of biliary injury following open cholecystectomy litigated in the US between 1970 and1991, median jury verdict awards were $500,000 , about twice that of out-of-court settlements[1].

One of the rarest, but most serious, complications is structural damage to the common hepatic or common bile ducts[2], [3]. During laparoscopic cholecystectomy such serious damage has been occurring more frequently than during the open operation, averaging one in every 200 cases.

The problem may arise because the surgeon does not establish and maintain the anatomical landmarks[3a] known as the triangle of Calot[3b]

Furthermore, it is not sufficient for the surgeon to identify a duct that appears to leave the gallbladder, since the Common Bile Duct (CBD) may be "tented" behind the gallbladder by adhesions.  The standard [3c] is to visualise the actual junction of the cystic duct with the gallbladder. 

Structural damage to the bile ducts often requires extensive corrective surgery. When it is diagnosed late, the mortality may be as high as 18% [4].

Surgical inexperience with the laparoscopic technique is a documented factor[5]. Clinical research has attempted to quantify the increased risks of biliary injury during the individual surgeon's learning period, perhaps the first fifty cases [6]. Part of the problem is a reluctance to convert to an open cholecystectomy when complications do occur[7].

PRACTICE POINT Establish in detail the specifics of the defendant's training and experience in laparoscopic cholecystectomy.

In a 1992 study of questionnaires completed by 149 surgeons from academic and private US practice, three-quarters thought that a course involving a hands-on animal laboratory should be required. 84% would require a preceptorship, involving some half-a-dozen cases as assistant and half-a-dozen as surgeon. One-third believed that a surgeon should undertake a probationary period of another dozen cases, with review of complications, before being given full privileges[7].

 

Quantum of Damages

Short-term [8] and 5-year [9] clinical studies confirm that the vast majority of patients do well after surgical repair of bile-ducts that have been injured at laparoscopic cholecystectomy. 

Quality of Life is reduced on psychological measures, but not on physical or emotional [10, full-text].  Consistent with other research, pursuing medical malpractice litigation is associated with worsened Quality of Life in all three areas. 

 

Bile Leak

Leakage of bile into the abdomen, unaccompanied by bile-duct injury, occurs after 1%[11] - 2%[12] of laparoscopic cholecystectomies and is not de facto evidence of substandard surgical technique.  In particular, such leaks generally occur from the cystic duct stump and, in the current state of knowledge, may not be preventable when subsequent shrinking of inflamed tissue or necrosis of the stump causes the clips to slip. 

However, if there is circumstantial evidence of incorrect application of clips, or injudicious use of diathermy or laser[12], surgery may be found to have been negligent.  Similarly, it has been argued that if an accessory hepatic duct of Luschka is found, it should be sutured, since this too may be a source of bile leak.  

In most cases the leak settles spontaneously and only a minority require surgical intervention.  Drainage of biloma through the skin during radiographic screening[13] and laparoscopic drainage[14] are alternative approaches

 

 

Copyright © 2009 Electronic Handbook of Legal Medicine