Incidence, Risk Factors, and Prevention of Biliary Tract Injuries during Laparoscopic Cholecystectomy in Switzerland

Abstract

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3-year period (1995-1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3-98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T-drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux-en-Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long-term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.

A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

“…[12] Several authors have shown that conversion from LC to OP can result in a significant change in the outcome for the patient, as it has higher post-operative complications and requires longer hospital stay. [13,14] The conversion rate in our study was 11% (11 of 100), which compares well with the incidence reported in the literature, which varies from 2% to 15%. [15,16] A similar study by Tiwary et al which included 536 patients who underwent LC reported overall conversion rate of 7.81%.…”

Curva de aprendizado e lesões iatrogênicas em colecistectomias videolaparoscópicas

“…Segundo Melo 19,20 ao se realizar treinamento em videocirurgia, é necessária a aprendizagem de habilidades psicomotoras indispensáveis ao método laparoscópico. A coordenação olho-mão é mais rapidamente desenvolvida em indivíduos mais jovens e representa um fator facilitador na aquisição de habilidades motoras necessárias à videocirurgia [19][20][21] . A habilidade requerida para a cirurgia pode ser adquirida através de um número variá-vel de horas de treinamento, que somado ao conhecimento da anatomia e da técnica operatória, tornam o cirurgião capacitado à realização de operações cada vez mais complexas 20 .…”

“…A aprendizagem se faz através de três áreas distintas: a cognitiva, relacionada ao conhecimento, a afetiva, associada aos sentimentos e a psicomotora que é relacionada ao fazer propriamente dito e que se traduz pelas ações de natureza física [21][22][23] . A capacidade de aprender difere entre os indivíduos, mas obedece a um mesmo padrão entre seres humanos que já atingiram a maturidade, e só é influenciada negativamente pela a idade quando as enfermidades deterioraram as áreas da aprendizagem afetando em especial o domínio psicomotor 14,19,20 .…”

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

“…Although the latter point is controversial, these injuries are more often seen in difficult cases (40)(41)(42)(43)(44)(45)(46)(47)(48). Lack of experience is a risk factor, but injuries may also occur in the hands of experienced surgeons (49,50).…”