Complications of Cholecystectomy - Department of …downstatesurgery.org/files/cases/Complications_Cholecystectomy.pdfBiliary Tract PathophysiologyBiliary Tract Pathophysiology

Complications ofComplications ofComplications of Complications of CholecystectomyCholecystectomyCholecystectomyCholecystectomy

Irina Kovatch, PGYIrina Kovatch, PGY--33Morbidity and MortalityMorbidity and Mortality

Kings County Hospital CenterKings County Hospital Centerg y pg y pJuly 26July 26thth -- August 10August 10thth 20092009

www.downstatesurgery.org

Case PresentationCase PresentationPt is a 43 year old male Pt is a 43 year old male CC: RUQ/epigastric abdominal pain and N/V x 1 dayCC: RUQ/epigastric abdominal pain and N/V x 1 dayCC: RUQ/epigastric abdominal pain and N/V x 1 dayCC: RUQ/epigastric abdominal pain and N/V x 1 dayHPI: similar pain x1 week, postHPI: similar pain x1 week, post--prandial, prandial, intermittent, lasted several hrs, resolved intermittent, lasted several hrs, resolved , ,, ,spontaneouslyspontaneouslyPMH: obesity, depressionPMH: obesity, depressiony py pPSH: deniedPSH: deniedMeds: deniesMeds: deniesNKDANKDASH: denied x3SH: denied x3SH: denied x3SH: denied x3


Case PresentationCase PresentationVS: T 98.0, BP 146/99, HR 70, RR 18VS: T 98.0, BP 146/99, HR 70, RR 18PE: A&Ox3, NAD. Abd soft, tender in RUQ/ PE: A&Ox3, NAD. Abd soft, tender in RUQ/

i i M h ’ i b di i M h ’ i b depigastric area, neg Murphy’s sign, no rebound, no epigastric area, neg Murphy’s sign, no rebound, no hernias, nonhernias, non--distended, BS+distended, BS+Labs:Labs:Labs: Labs:

CBC: CBC: 17.217.2/ 13.8/ 41.2/ 361, / 13.8/ 41.2/ 361, N 90%N 90%BMP: 135/ 4 0/BMP: 135/ 4 0/ 9696/ 26/ 16/ 0 86/ 137/ 26/ 16/ 0 86/ 137BMP: 135/ 4.0/ BMP: 135/ 4.0/ 9696/ 26/ 16/ 0.86/ 137/ 26/ 16/ 0.86/ 137LFTs: 7.6/ 4.9/ 27/ 32/ 83/ 0.7, Lipase LFTs: 7.6/ 4.9/ 27/ 32/ 83/ 0.7, Lipase 167167Coags: 13.8/ 26.9/ 1.4Coags: 13.8/ 26.9/ 1.4Coags: 13.8/ 26.9/ 1.4Coags: 13.8/ 26.9/ 1.4UA: negUA: neg

EKG: NSREKG: NSRCXR: wnlCXR: wnl


CT scanCT scanwww.downstatesurgery.org

CT scanCT scanwww.downstatesurgery.org

Case PresentationCase PresentationImaging:Imaging:

CT Abd: cholelithiasis 1.7cm in the gallbladder CT Abd: cholelithiasis 1.7cm in the gallbladder k i h i h l i i fl hk i h i h l i i fl hneck with pericholecystic inflammatory changesneck with pericholecystic inflammatory changes

RUQ US: 2.1 cm stone in gallbladder neck, no RUQ US: 2.1 cm stone in gallbladder neck, no gallbladder wall thickening no pericholecysticgallbladder wall thickening no pericholecysticgallbladder wall thickening, no pericholecystic gallbladder wall thickening, no pericholecystic fluid, negative sonographic Murphy’s signfluid, negative sonographic Murphy’s sign

Pt was admitted to surgical service, started on IV Pt was admitted to surgical service, started on IV g ,g ,cipro/flagyl and taken to OR on HD1 for cipro/flagyl and taken to OR on HD1 for cholecystectomycholecystectomyA d l i dA d l i dAttempted laparoscopic, converted to open Attempted laparoscopic, converted to open cholecystectomy was performedcholecystectomy was performedGallbladder was thick edematous intrahepatic withGallbladder was thick edematous intrahepatic withGallbladder was thick, edematous, intrahepatic with Gallbladder was thick, edematous, intrahepatic with impacted large stone in the fundusimpacted large stone in the fundus


Case PresentationCase PresentationGallbladder was entered in order to confirm location Gallbladder was entered in order to confirm location of the cystic duct, mucosa appeared gangrenousof the cystic duct, mucosa appeared gangrenousof the cystic duct, mucosa appeared gangrenousof the cystic duct, mucosa appeared gangrenousCystic duct was tied with silk 2Cystic duct was tied with silk 2--0 suture0 sutureJP drain was left in Morrison’s pouchJP drain was left in Morrison’s pouchJP drain was left in Morrison s pouchJP drain was left in Morrison s pouchPath: gallbladder with acute, necrotizing, Path: gallbladder with acute, necrotizing, hemorrhagic and chronic cholecystitis with impactedhemorrhagic and chronic cholecystitis with impactedhemorrhagic and chronic cholecystitis with impacted hemorrhagic and chronic cholecystitis with impacted cholelithiasischolelithiasisPOD1: WBC 12.7, JP 25cc serosangPOD1: WBC 12.7, JP 25cc serosang, g, gPOD2: WBC 9.9, JP 190cc biliousPOD2: WBC 9.9, JP 190cc biliousPOD3: WBC 10.6, JP 500cc serosangPOD3: WBC 10.6, JP 500cc serosangPOD3: WBC 10.6, JP 500cc serosangPOD3: WBC 10.6, JP 500cc serosangPOD4: WBC 11.8, JP 400 bilious, plan: MRCPPOD4: WBC 11.8, JP 400 bilious, plan: MRCP


Case PresentationCase PresentationMRCP: abnormal small fluid collection adjacent to cystic MRCP: abnormal small fluid collection adjacent to cystic duct extending into subhepatic space, highly suspicious duct extending into subhepatic space, highly suspicious g p p g y pg p p g y pfor cystic duct stump leak, no intrahepatic biliary ductal for cystic duct stump leak, no intrahepatic biliary ductal dilatationdilatationPOD8: ERCP, shincterotomy, common bile duct stent POD8: ERCP, shincterotomy, common bile duct stent placementplacementPOD9: Amylase 245, Lipase 1005, JP drainage decreasedPOD9: Amylase 245, Lipase 1005, JP drainage decreasedPOD10: Amylase 175, Lipase 615POD10: Amylase 175, Lipase 615POD12: WBC 6.8, JP drain removed (10cc), pt POD12: WBC 6.8, JP drain removed (10cc), pt discharged discharged Plan: f/u with GI in 4 weeks to remove stentPlan: f/u with GI in 4 weeks to remove stent


HistoryHistoryHistoryHistory

In 1867, John Stough Bobb of Indianapolis performedIn 1867, John Stough Bobb of Indianapolis performedIn 1867, John Stough Bobb of Indianapolis performed In 1867, John Stough Bobb of Indianapolis performed cholecystotomy, removed gallstones and sutured the cholecystotomy, removed gallstones and sutured the gallbladder in a 32gallbladder in a 32--yearyear--old woman with massive old woman with massive gallbladder hydrops gallbladder hydrops -- first biliary tract operationfirst biliary tract operationIn 1882, Carl Langenbuch of Berlin performed first In 1882, Carl Langenbuch of Berlin performed first cholecystectomy for a patient with biliary coliccholecystectomy for a patient with biliary colicIn 1986, Erich Mühe of Germany performed the first In 1986, Erich Mühe of Germany performed the first laparoscopic cholecystectomylaparoscopic cholecystectomy


AnatomyAnatomyyyCommon hepatic duct lays anterolateral to the Common hepatic duct lays anterolateral to the hepatic artery and portal vein in the hepatoduodenal hepatic artery and portal vein in the hepatoduodenal p y p pp y p pligamentligamentCommon bile duct length is 5Common bile duct length is 5--9 cm which is 9 cm which is divided into supraduodenal retroduodenal anddivided into supraduodenal retroduodenal anddivided into supraduodenal, retroduodenal, and divided into supraduodenal, retroduodenal, and intrapancreatic segmentsintrapancreatic segmentsGallbladder is a pearGallbladder is a pear--shaped organ which is 7shaped organ which is 7--10 10

i l hi l h i di d i fi di d i fcm in length, 3cm in length, 3--5 cm in diameter, and capacity of 5 cm in diameter, and capacity of 3030--60 ml60 mlCystic duct length is 1Cystic duct length is 1--5 cm and diameter 35 cm and diameter 3--7 mm7 mmCystic duct length is 1Cystic duct length is 1 5 cm and diameter 35 cm and diameter 3 7 mm7 mmAn accessory hepatic duct or cholecystohepatic An accessory hepatic duct or cholecystohepatic duct (duct of Luschka) may also enter the duct (duct of Luschka) may also enter the gallbladder thro gh the gallbladder fossagallbladder thro gh the gallbladder fossagallbladder through the gallbladder fossagallbladder through the gallbladder fossa


Cystic ArteryCystic ArteryCystic ArteryCystic Artery

Gallbladder is supplied by a single cystic artery, butGallbladder is supplied by a single cystic artery, butGallbladder is supplied by a single cystic artery, but Gallbladder is supplied by a single cystic artery, but in 12% of cases a double cystic artery may exist in 12% of cases a double cystic artery may exist (anterior and posterior)(anterior and posterior)The origin and course of the cystic artery is one of the The origin and course of the cystic artery is one of the most variable in the body: may originate from left most variable in the body: may originate from left hepatic, common hepatic, gastroduodenal, or superior hepatic, common hepatic, gastroduodenal, or superior mesenteric arteries mesenteric arteries Cystic artery usually lies superior to the cystic duct Cystic artery usually lies superior to the cystic duct and passes posterior to the common hepatic ductand passes posterior to the common hepatic duct


Anatomy of the Biliary SystemAnatomy of the Biliary Systemwww.downstatesurgery.org

Triangle of CalotTriangle of CalotTriangle of CalotTriangle of Calot

Boundaries:Boundaries:Boundaries: Boundaries: common hepatic common hepatic duct, liver, cystic duct, liver, cystic ductductWithin triangle: Within triangle: cystic artery, right cystic artery, right heparic artery and heparic artery and

ti d t l hti d t l hcystic duct lymph cystic duct lymph nodenode


Vascular Supply of Biliary Tree Vascular Supply of Biliary Tree pp y ypp y y

Blood supply to extrahepatic biliary tree originates:Blood supply to extrahepatic biliary tree originates:Blood supply to extrahepatic biliary tree originates:Blood supply to extrahepatic biliary tree originates:proximally: right hepatic and cystic arteriesproximally: right hepatic and cystic arteriesdistally: gastroduodenal and posterosuperiordistally: gastroduodenal and posterosuperiordistally: gastroduodenal and posterosuperior distally: gastroduodenal and posterosuperior pancreaticoduodenal arteries pancreaticoduodenal arteries these arteries supply common bile and commonthese arteries supply common bile and commonthese arteries supply common bile and common these arteries supply common bile and common hepatic ducts through branches running parallel to hepatic ducts through branches running parallel to the duct in the 3the duct in the 3-- and 9and 9--o’clock positionso’clock positions

Extrahepatic biliary tree is vulnerable to ischemic Extrahepatic biliary tree is vulnerable to ischemic injury during dissection and can result in biliary injury during dissection and can result in biliary stricture or leak postoperativelystricture or leak postoperatively


Biliary Tract PathophysiologyBiliary Tract PathophysiologyBiliary Tract PathophysiologyBiliary Tract Pathophysiology

Symptoms are usually the result of obstruction, Symptoms are usually the result of obstruction, y p y ,y p y ,infection, or bothinfection, or bothObstruction can be extramural (e.g., pancreatic Obstruction can be extramural (e.g., pancreatic cancer), intramural (cholangiocarcinoma), or cancer), intramural (cholangiocarcinoma), or intraluminal (choledocholithiasis)intraluminal (choledocholithiasis)Biliary infections are usually due to three factors:Biliary infections are usually due to three factors:Biliary infections are usually due to three factors: Biliary infections are usually due to three factors: susceptible host, sufficient innoculum, and stasissusceptible host, sufficient innoculum, and stasisMost common symptoms related to biliary tract Most common symptoms related to biliary tract os co o sy p o s e ed o b y cos co o sy p o s e ed o b y cdisease are abdominal pain, jaundice, fever, and disease are abdominal pain, jaundice, fever, and nausea and vomitingnausea and vomiting


Calculous Biliary DiseaseCalculous Biliary Diseasewww.downstatesurgery.org

CholecystectomyCholecystectomywww.downstatesurgery.org

Laparoscopic CholecystectomyLaparoscopic CholecystectomyContraindications include coagulopathy, severe Contraindications include coagulopathy, severe COPD, end stage liver disease, and CHFCOPD, end stage liver disease, and CHFMajor contraindication to completing a laparoscopic Major contraindication to completing a laparoscopic cholecystectomy is inability to clearly identify all of cholecystectomy is inability to clearly identify all of th t i t tth t i t tthe anatomic structuresthe anatomic structuresConversion rate for elective laparoscopic Conversion rate for elective laparoscopic cholecystectomy is around 5%cholecystectomy is around 5%cholecystectomy is around 5%cholecystectomy is around 5%Conversion rate in the setting of acute cholecystitis Conversion rate in the setting of acute cholecystitis may be as high as 30%may be as high as 30%Conversion to an open procedure is not a failure and Conversion to an open procedure is not a failure and the possibility should be discussed with the patient the possibility should be discussed with the patient

ti lti lpreoperativelypreoperatively


Laparoscopic CholecystectomyLaparoscopic CholecystectomyLaparoscopic CholecystectomyLaparoscopic Cholecystectomy

Pneumoperitoneium is created with CO2 gasPneumoperitoneium is created with CO2 gasOpen technique using Hasson bluntOpen technique using Hasson blunt--tipped cannula tipped cannula often used following previous abdominal surgeryoften used following previous abdominal surgeryClosed technique involves use Veress hollow Closed technique involves use Veress hollow insuflation needle with a retractable cutting sheathinsuflation needle with a retractable cutting sheathNo difference in inadvertent bowel or tissue injury No difference in inadvertent bowel or tissue injury between the two techniquesbetween the two techniques

The laparoscope is placed through a 10The laparoscope is placed through a 10--mm port just mm port just above the umbilicusabove the umbilicus


Trochar PlacementTrochar Placement

Additional ports are Additional ports are placed under direct placed under direct vision in the vision in the

i t i di t i depigastrium and epigastrium and subcostally in the subcostally in the midclavicular andmidclavicular andmidclavicular and midclavicular and near the anterior near the anterior axillary linesaxillary linesyy


Laparoscopic TechniqueLaparoscopic TechniqueThe gallbladder is retracted cephalad using the The gallbladder is retracted cephalad using the grasper on the gallbladder fundusgrasper on the gallbladder fundusThe gallbladder infundibulum is retractedThe gallbladder infundibulum is retractedThe gallbladder infundibulum is retracted The gallbladder infundibulum is retracted inferolaterally to expose triangle of Calotinferolaterally to expose triangle of CalotThe peritoneum overlying the gallbladder The peritoneum overlying the gallbladder i f dib l k d i d i di id d bl li f dib l k d i d i di id d bl linfundibulum, neck and cystic duct is divided bluntly, infundibulum, neck and cystic duct is divided bluntly, exposing the cystic duct exposing the cystic duct Junction of the gallbladder and cystic duct isJunction of the gallbladder and cystic duct isJunction of the gallbladder and cystic duct is Junction of the gallbladder and cystic duct is identified and dissection continues until the cystic identified and dissection continues until the cystic artery and duct are clearly seen entering the artery and duct are clearly seen entering the gallbladder visualization of common bile duct is notgallbladder visualization of common bile duct is notgallbladder, visualization of common bile duct is not gallbladder, visualization of common bile duct is not necessarynecessaryPartial dissection of the base of gallbladder off the Partial dissection of the base of gallbladder off the li b d bl id tifi ti f ll th t dli b d bl id tifi ti f ll th t dliver bed enables identification of all the anatomy and liver bed enables identification of all the anatomy and minimizes risk for bile duct injuryminimizes risk for bile duct injury


Laparoscopic TechniqueLaparoscopic Techniquewww.downstatesurgery.org

Laparoscopic CholecystectomyLaparoscopic CholecystectomyClips are placed proximally and distally on cystic artery Clips are placed proximally and distally on cystic artery and duct and both are dividedand duct and both are dividedG llbl dd i di d f h llbl dd f i hG llbl dd i di d f h llbl dd f i hGallbladder is dissected out of the gallbladder fossa with Gallbladder is dissected out of the gallbladder fossa with electrocautery and removed through the umbilical port electrocautery and removed through the umbilical port using plastic specimen retrieval bagusing plastic specimen retrieval bagusing plastic specimen retrieval bagusing plastic specimen retrieval bagOperative field is searched for hemostasis before Operative field is searched for hemostasis before complete separation of the gallbladder from the liver bedcomplete separation of the gallbladder from the liver bedAny bile or blood that has accumulated should be Any bile or blood that has accumulated should be irrigated and suctionedirrigated and suctionedA b bil l i l k h ldA b bil l i l k h ldAny concern about bile accumulation or leak should Any concern about bile accumulation or leak should prompt placement of a closedprompt placement of a closed--suction drain and left suction drain and left underneath the right lobe of the liver close to gallbladderunderneath the right lobe of the liver close to gallbladderunderneath the right lobe of the liver close to gallbladder underneath the right lobe of the liver close to gallbladder fossafossa


Open CholecystectomyOpen CholecystectomyOpen CholecystectomyOpen Cholecystectomy

Usually performed either as a conversion from anUsually performed either as a conversion from anUsually performed either as a conversion from an Usually performed either as a conversion from an attempted laparoscopic cholecystectomy or as a attempted laparoscopic cholecystectomy or as a second procedure in a patient requiring laparotomy second procedure in a patient requiring laparotomy for another reasonfor another reasonPerformed in any patient who cannot tolerate Performed in any patient who cannot tolerate pneumoperitoneum because of poor pulmonary or pneumoperitoneum because of poor pulmonary or cardiac reserve and in patients in whom gallbladder cardiac reserve and in patients in whom gallbladder

i t d ti li t d ti lcancer is suspected preoperativelycancer is suspected preoperatively


Open CholecystectomyOpen CholecystectomyOpen CholecystectomyOpen Cholecystectomywww.downstatesurgery.org

Open TechniqueOpen TechniqueOpen TechniqueOpen Technique

Performed similarly to the laparoscopic approachPerformed similarly to the laparoscopic approachPerformed similarly to the laparoscopic approachPerformed similarly to the laparoscopic approachAfter cystic artery and duct identified, the gallbladder After cystic artery and duct identified, the gallbladder is dissected from the liver bed starting with the is dissected from the liver bed starting with the ggfundusfundusIn retrograde technique dissection is initiated with the In retrograde technique dissection is initiated with the g qg qfundus and the artery and duct are identified, ligated fundus and the artery and duct are identified, ligated and divided as a final stepand divided as a final step


Biliary LeakBiliary Leakyy

Leaks from the cystic duct stump or an unrecognized Leaks from the cystic duct stump or an unrecognized d f L hk b bl id f L hk b bl iduct of Luschka may be problematic duct of Luschka may be problematic The most common etiology for a cystic duct stump The most common etiology for a cystic duct stump l k i i fl ti d th d t i th ttil k i i fl ti d th d t i th ttileak is an inflammation around the duct in the setting leak is an inflammation around the duct in the setting of acute cholecystitis, which dislodges placed clips of acute cholecystitis, which dislodges placed clips Bile leaks commonly present shortly afterBile leaks commonly present shortly afterBile leaks commonly present shortly after Bile leaks commonly present shortly after cholecystectomy (within 1 week) with right upper cholecystectomy (within 1 week) with right upper quadrant pain, fever, chills, and hyperbilirubinemiaquadrant pain, fever, chills, and hyperbilirubinemiaquadrant pain, fever, chills, and hyperbilirubinemia quadrant pain, fever, chills, and hyperbilirubinemia CT scan and ultrasound will confirm presence of a CT scan and ultrasound will confirm presence of a complex fluid collection in the right upper quadrant complex fluid collection in the right upper quadrant p g pp qp g pp q


Biliary LeakBiliary LeakOperative intervention with wide drainage is only Operative intervention with wide drainage is only indicated if the patient is in septic shock indicated if the patient is in septic shock Attempts at early repair are dangerous and doomed Attempts at early repair are dangerous and doomed for failure because of the inflammatory response for failure because of the inflammatory response incited by the bile leakincited by the bile leakincited by the bile leak incited by the bile leak Percutaneous drainage of intraPercutaneous drainage of intra--abdominal fluid abdominal fluid collections followed by an endoscopic biliary stenting collections followed by an endoscopic biliary stenting

l t l k ith t d f til t l k ith t d f tiresolves most leaks without need for operative resolves most leaks without need for operative intervention intervention If bile leaks fail to resolve after 6 weeks, further If bile leaks fail to resolve after 6 weeks, further ,,imaging with MRC and endoscopic imaging may be imaging with MRC and endoscopic imaging may be necessary to rule out a common bile duct injury necessary to rule out a common bile duct injury


Bile Duct Injury and LigationBile Duct Injury and LigationBile Duct Injury and LigationBile Duct Injury and Ligation

Most benign strictures follow iatrogenic bile duct Most benign strictures follow iatrogenic bile duct g gg ginjury, most commonly during laparoscopic injury, most commonly during laparoscopic cholecystectomycholecystectomyMost injuries are recognized intraoperatevely or Most injuries are recognized intraoperatevely or during the early postoperative periodduring the early postoperative periodLongLong term sequelae of unrecognized orterm sequelae of unrecognized orLongLong--term sequelae of unrecognized or term sequelae of unrecognized or inappropriately managed biliary strictures may lead to inappropriately managed biliary strictures may lead to recurrent cholangitis, secondary biliary cirrhosis, and recurrent cholangitis, secondary biliary cirrhosis, and portal hypertensionportal hypertension


Biliary InjuriesBiliary InjuriesIn open cholecystectomy is 0.1 In open cholecystectomy is 0.1 -- 0.2%0.2%In laparoscopic cholecystectomy reported around 0.3In laparoscopic cholecystectomy reported around 0.3--0 85% i l l t di0 85% i l l t di0.85% in several large studies0.85% in several large studiesFactors involved in the occurrence of bile duct Factors involved in the occurrence of bile duct injuries include acute or chronic inflammation, injuries include acute or chronic inflammation, j ,j ,obesity, anatomic variations and bleedingobesity, anatomic variations and bleedingInjury rate is increased in patients with acute Injury rate is increased in patients with acute cholecystitis pancreatitis cholangitis and obstructivecholecystitis pancreatitis cholangitis and obstructivecholecystitis, pancreatitis, cholangitis and obstructive cholecystitis, pancreatitis, cholangitis and obstructive jaundicejaundiceInadequate exposure and failure to identify structures Inadequate exposure and failure to identify structures b f li i di idi h hb f li i di idi h hbefore ligating or dividing them are the most common before ligating or dividing them are the most common cause of biliary injurycause of biliary injuryAs surgeon experience increases beyond 20 cases, theAs surgeon experience increases beyond 20 cases, theAs surgeon experience increases beyond 20 cases, the As surgeon experience increases beyond 20 cases, the bile duct injury rate decreasesbile duct injury rate decreases


Common Bile Duct TransectionCommon Bile Duct TransectionCommon Bile Duct TransectionCommon Bile Duct Transection

Classic injury occurs Classic injury occurs when excessive when excessive cephalad retraction cephalad retraction

f th llbl ddf th llbl ddof the gallbladder of the gallbladder may align the cystic may align the cystic duct with theduct with theduct with the duct with the common bile duct, common bile duct, allowing the latter to allowing the latter to ggbe mistaken for the be mistaken for the cystic ductcystic duct


Biliary InjuryBiliary InjuryBiliary InjuryBiliary Injury

Electrocautery may lead to thermal injuryElectrocautery may lead to thermal injuryElectrocautery may lead to thermal injuryElectrocautery may lead to thermal injuryDissection deep into the liver parenchyma may cause Dissection deep into the liver parenchyma may cause injury to intrahepatic ductsinjury to intrahepatic ductsj y pj y pPoor clip placement close to hilar area or to structures Poor clip placement close to hilar area or to structures not well visualized can result in a clip across the bile not well visualized can result in a clip across the bile ppductductIntraoperative cholangiogram may limit the extent of Intraoperative cholangiogram may limit the extent of injury, but does not seem to prevent itinjury, but does not seem to prevent it


PresentationPresentation

Patients with bile duct injuries can present Patients with bile duct injuries can present intraoperatively in the early postoperative period orintraoperatively in the early postoperative period orintraoperatively, in the early postoperative period, or intraoperatively, in the early postoperative period, or months or years after the initial injurymonths or years after the initial injury25% of major ductal injuries are recognized 25% of major ductal injuries are recognized i t ti l b f bil l k b li t ti l b f bil l k b lintraoperatively because of bile leakage, an abnormal intraoperatively because of bile leakage, an abnormal cholangiogram, or late recognition of the anatomycholangiogram, or late recognition of the anatomyMost common presentation of a complete occlusion Most common presentation of a complete occlusion p pp pof the common bile duct is jaundice with or without of the common bile duct is jaundice with or without abdominal painabdominal painPatients may also present months or years after thePatients may also present months or years after thePatients may also present months or years after the Patients may also present months or years after the surgery with cholangitis or cirrhosis secondary to a surgery with cholangitis or cirrhosis secondary to a biliary tract injurybiliary tract injury


Diagnosis and ManagementDiagnosis and ManagementHistorically, after open cholecystectomy 10% of Historically, after open cholecystectomy 10% of patients presented within first week, 70% within 6 patients presented within first week, 70% within 6

th d 80% ithi 1th d 80% ithi 1months, and 80% within 1 yearmonths, and 80% within 1 yearIn general patients with a bile leak will present early, In general patients with a bile leak will present early, whereas patients with postoperative biliary strictures whereas patients with postoperative biliary strictures p p p yp p p yalone present with jaundice or cholangitis months to alone present with jaundice or cholangitis months to years after the initial injuryyears after the initial injuryUS or CT should be performed in patients with signsUS or CT should be performed in patients with signsUS or CT should be performed in patients with signs US or CT should be performed in patients with signs of abdominal pain or peritonitis, sepsis, or any other of abdominal pain or peritonitis, sepsis, or any other clinical suspicion of bilomaclinical suspicion of bilomaM d d h i i f h di iM d d h i i f h di iManagement depends on the timing of the diagnosis Management depends on the timing of the diagnosis and the extent and level of injuryand the extent and level of injuryInappropriate management of biliary strictures mayInappropriate management of biliary strictures mayInappropriate management of biliary strictures may Inappropriate management of biliary strictures may result in biliary cirrhosis and cholangitisresult in biliary cirrhosis and cholangitis


Intraoperative ManagementIntraoperative ManagementIntraoperative ManagementIntraoperative Management

Isolated, small, nonIsolated, small, non--cauterycautery--based partial lateral bile based partial lateral bile , ,, , yy ppduct injury can be managed with placement of a T duct injury can be managed with placement of a T tubetubeIf the biliary injury is more extensive (e g involvesIf the biliary injury is more extensive (e g involvesIf the biliary injury is more extensive (e.g. involves If the biliary injury is more extensive (e.g. involves >50% of the circumference), an end to side >50% of the circumference), an end to side choledochojejunostomy with a Rouxcholedochojejunostomy with a Roux--enen--Y loop of Y loop of jejunum should be performedjejunum should be performedjejunum should be performedjejunum should be performedDucts larger than 3 mm need to be reDucts larger than 3 mm need to be re--implanted, implanted, those less than 3 mm can be safely ligatedthose less than 3 mm can be safely ligatedIf uncertain or underexperienced, placing a drain If uncertain or underexperienced, placing a drain followed by referral to an experienced center is the followed by referral to an experienced center is the most appropriate course of actionmost appropriate course of actionmost appropriate course of actionmost appropriate course of action


Intraoperative ManagementIntraoperative Managementwww.downstatesurgery.org

RepairRepairSuccessful repair of biliary strictures requires Successful repair of biliary strictures requires adherence to specific surgical principles:adherence to specific surgical principles:p g p pp g p p

Use of proximal bile duct with minimal Use of proximal bile duct with minimal inflammationinflammationCreation of a tensionCreation of a tension--free anastomosis with the use free anastomosis with the use of a Rouxof a Roux--enen--Y jejunal limbY jejunal limbDi tDi t tt t it iDirect mucosaDirect mucosa--toto--mucosa anastomosismucosa anastomosis

Primary repair of the bile duct is associated with a 40Primary repair of the bile duct is associated with a 40--50% long50% long--term failure rateterm failure rate50% long50% long--term failure rateterm failure rateThe use of a RouxThe use of a Roux--enen--Y jejunal limb allows for the Y jejunal limb allows for the creation of an “access loop” for future interventional creation of an “access loop” for future interventional ppradiologic accessradiologic access


Postoperative ManagementPostoperative ManagementPostoperative ManagementPostoperative Management

Multidisciplinary team consisting of experiencedMultidisciplinary team consisting of experiencedMultidisciplinary team consisting of experienced Multidisciplinary team consisting of experienced interventional radiologist, endoscopist, and interventional radiologist, endoscopist, and experienced hepatobiliary surgeonexperienced hepatobiliary surgeon should plan the should plan the p p y gp p y g ppfollowing specific goals:following specific goals:

Control of infection (abscess or cholangitis)Control of infection (abscess or cholangitis)( g )( g )Drain the bilomaDrain the bilomaComplete the cholangiographyComplete the cholangiographyp g g p yp g g p yProvide definitive therapy with controlled Provide definitive therapy with controlled reconstruction or stentingreconstruction or stentinggg


Postoperative managementPostoperative managementPatients should be stabilized with IV Abx and imagePatients should be stabilized with IV Abx and image--guided percutaneous drainage of any fluid collectionsguided percutaneous drainage of any fluid collectionsCh l i h h ld b f d t t bli hCh l i h h ld b f d t t bli hCholangiography should be performed to establish Cholangiography should be performed to establish the presence of ductal stricture, identify the level of the presence of ductal stricture, identify the level of stricture and identify the nature of injurystricture and identify the nature of injuryERCP may be easier to obtain in a patient with biliary ERCP may be easier to obtain in a patient with biliary stricture and cholangitis who requires urgent stricture and cholangitis who requires urgent cholangiography and biliary decompression, howevercholangiography and biliary decompression, howevercholangiography and biliary decompression, however cholangiography and biliary decompression, however it is only useful in patients with bile duct continuity it is only useful in patients with bile duct continuity Cystic duct leaks or small injuries can be treated with Cystic duct leaks or small injuries can be treated with endoscopic stentingendoscopic stentingendoscopic stentingendoscopic stentingIf biliary stricture is too tight to pass with ERCP, If biliary stricture is too tight to pass with ERCP, PTC may be performed for proximal biliary PTC may be performed for proximal biliary y p p yy p p ydecompressiondecompression


Radiologic and Endoscopic TechniquesRadiologic and Endoscopic TechniquesEndoscopic and percutaneous methods of dilation Endoscopic and percutaneous methods of dilation have equivalent efficacyhave equivalent efficacyEndoscopic dilation is often used in patients with a Endoscopic dilation is often used in patients with a dominant extrahepatic stricture causing clinical dominant extrahepatic stricture causing clinical symptomssymptomssymptomssymptomsComplications are high for both techniques (~35%) Complications are high for both techniques (~35%) and include hemobilia, cholangitis, bile leaks, and and include hemobilia, cholangitis, bile leaks, and , g , ,, g , ,pancreatitispancreatitisMultiple sessions of dilation are often required to Multiple sessions of dilation are often required to

hi lhi lachieve longachieve long--term success rateterm success rateEndoscopic stenting and drainage is a successful Endoscopic stenting and drainage is a successful treatment option for cystic duct leak or smalltreatment option for cystic duct leak or smalltreatment option for cystic duct leak or small treatment option for cystic duct leak or small common bile duct leaks following cholecystectomycommon bile duct leaks following cholecystectomy


OutcomesOutcomesB t lt bt i d h th i j iB t lt bt i d h th i j iBest results are obtained when the injury is Best results are obtained when the injury is recognized and repaired during the cholecystectomy recognized and repaired during the cholecystectomy Percutaneous balloon dilation with stenting has aPercutaneous balloon dilation with stenting has aPercutaneous balloon dilation with stenting has a Percutaneous balloon dilation with stenting has a lower success rate than operative repair lower success rate than operative repair Postoperative injuries identified in the presence of Postoperative injuries identified in the presence of p j pp j pconcomitant biliary leak should be repaired once the concomitant biliary leak should be repaired once the biliary leak has subsided and tissue planes are less biliary leak has subsided and tissue planes are less inflamed (usually after 6 weeks)inflamed (usually after 6 weeks)inflamed (usually after 6 weeks) inflamed (usually after 6 weeks) Common complications of biliary reconstruction Common complications of biliary reconstruction include recurrent cholangitis, external biliary fistula,include recurrent cholangitis, external biliary fistula,include recurrent cholangitis, external biliary fistula, include recurrent cholangitis, external biliary fistula, bile leak, and hemobilia and can be managed bile leak, and hemobilia and can be managed nonoperativelynonoperativelyRestenosis of a biliaryRestenosis of a biliary--enteric anastomosis occurs in enteric anastomosis occurs in ~ 10% of patients, and may manifest many years later~ 10% of patients, and may manifest many years later


Retained and Recurrent Biliary StonesRetained and Recurrent Biliary Stones

If stones are found shortly after the cholecystectomy, If stones are found shortly after the cholecystectomy, they are classified asthey are classified as retainedretained; those diagnosed; those diagnosedthey are classified as they are classified as retainedretained; those diagnosed ; those diagnosed months or years later are termed months or years later are termed recurrentrecurrentPatients will present most commonly shortly afterPatients will present most commonly shortly afterPatients will present most commonly shortly after Patients will present most commonly shortly after cholecystectomy with sharp, intense right upper cholecystectomy with sharp, intense right upper quadrant pain and jaundicequadrant pain and jaundiceRetained or recurrent stones following Retained or recurrent stones following cholecystectomy are best treated endoscopically cholecystectomy are best treated endoscopically -- a a generous endoscopic sphincterotomy will allow stone generous endoscopic sphincterotomy will allow stone retrieval as well as spontaneous passage of the stonesretrieval as well as spontaneous passage of the stones


Postcholecystectomy Abdominal PainPostcholecystectomy Abdominal Painwww.downstatesurgery.org

Postcholecystectomy painPostcholecystectomy painAbdominal pain or other symptoms originally Abdominal pain or other symptoms originally attributed to the gallbladder may persist or recur attributed to the gallbladder may persist or recur

h f h lh f h lmonths or years after cholecystectomymonths or years after cholecystectomyPatients presenting with right upper quadrant pain, Patients presenting with right upper quadrant pain, jaundice and chills shortly after cholecystectomyjaundice and chills shortly after cholecystectomyjaundice, and chills shortly after cholecystectomy jaundice, and chills shortly after cholecystectomy should be evaluated for retained stones or biliary leak should be evaluated for retained stones or biliary leak Other causes of abdominal pain in patients with Other causes of abdominal pain in patients with p pp pnormal liver function tests should also be investigated normal liver function tests should also be investigated Another possibility in a small number of patients with Another possibility in a small number of patients with

i i f ll i h l ii i f ll i h l ipersistent pain following cholecystectomy is persistent pain following cholecystectomy is abnormalities in the sphincter of Oddi such as abnormalities in the sphincter of Oddi such as stenosing papillitis or sphincter dysfunctionstenosing papillitis or sphincter dysfunctionstenosing papillitis or sphincter dysfunctionstenosing papillitis or sphincter dysfunction


ReferrencesReferrencesReferrencesReferrences

Branum G Schmitt C Baillie J et al: Management of major biliaryBranum G Schmitt C Baillie J et al: Management of major biliaryBranum G, Schmitt C, Baillie J, et al: Management of major biliary Branum G, Schmitt C, Baillie J, et al: Management of major biliary complications after laparoscopic cholecystectomy. Ann Surg 217:532complications after laparoscopic cholecystectomy. Ann Surg 217:532--541, 541, 1993 1993 Sicklick JK,Sicklick JK, Camp MS,Camp MS, Lillemoe KD,Lillemoe KD, et al:et al: Surgical management of bile Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: Perioperativeduct injuries sustained during laparoscopic cholecystectomy: Perioperativeduct injuries sustained during laparoscopic cholecystectomy: Perioperative duct injuries sustained during laparoscopic cholecystectomy: Perioperative results in 200 patients. results in 200 patients. Ann SurgAnn Surg 2005;2005; 241:786241:786--792 792 Lillemoe KD,Lillemoe KD, Martin SA,Martin SA, Cameron JL,Cameron JL, et al:et al: Major bile duct injuries Major bile duct injuries during laparoscopic cholecystectomy: Followduring laparoscopic cholecystectomy: Follow--up after combined surgical up after combined surgical

d di l id di l i A SA S 19971997 225 459225 459 468468and radiologic management. and radiologic management. Ann SurgAnn Surg 1997;1997; 225:459225:459--468468Gilchrist BF, Trunkey DD, Biliary Tract trauma. In Zuidema GD [ed]: Gilchrist BF, Trunkey DD, Biliary Tract trauma. In Zuidema GD [ed]: Shackelford's surgery of the alimentary tract, 3rd ed. WB Saunders, Shackelford's surgery of the alimentary tract, 3rd ed. WB Saunders, Philadelphia, 1991, pp 257 Philadelphia, 1991, pp 257 p , , ppp , , ppCameron J: Atlas of Surgery, vol 2. Philadelphia, BC Decker, 1994Cameron J: Atlas of Surgery, vol 2. Philadelphia, BC Decker, 1994


Documents

Complications of Cholecystectomy - Department of …downstatesurgery.org/files/cases/Complications_Cholecystectomy.pdfBiliary Tract PathophysiologyBiliary Tract Pathophysiology