Abstracts

INTRODUCTION

Cholecystectomy began to be held in the late 19^th century and was first described in 1882 by Carl Langenbuch. In the 20^th century its technical principles were created; major innovations have occurred in the last 25 years with the emergence of videolaparoscopic surgery¹1. Aguiar GB, Oliveira GIB, Silva JBS, Santos LS e Vieira SC. Lesão iatrogênica de vias biliares. Rev Col Bras Cir 2005; 32(2):69-73. Lau KN, Sindram D, Agee D. Bile duct injury after single incision laparoscopic cholecystectomy. JSLS 2010;14:587-591. ^{, 2}2. Buddingh KT, Nieuwenhuijs VB, van Buuren L and Hulscher JBF. Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 2011;25:2449-2461..

Surgical removal of the gallbladder is indicated in the treatment of biliary lithiasis and its complications, as well as neoplasms of the gallbladder. Iatrogenic injury to the bile ducts is the most feared complication, with an incidence of around 0.2 to 2.9%³3. Chiruvella A, Sarmiento JM, Sweeney JF, Lin E and Davis SS. Iatrogenic combined bile duct and right hepatic artery injury during single incision laparoscopic cholecystectomy. JSLS 2010; 14:268-271.. Factors such as laparoscopy, acute cholecystitis, scleroatrophic gallbladder, anatomic variations of the biliary tract, the curve for new surgeons and residents, are seen as the main causes of the higher incidence of iatrogenic injuries.¹⁰10. Lau WY and Lai ECH. Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int 2007;6:459-463.

The management of patients with these lesions is very complex, requiring experienced surgeons and mostly specialized services for the treatment of this complication. The prognosis is closely related to clinical conditions and the time between the identification of the lesion and surgical treatment⁵5. Crema E. Lesões iatrogênicas da vias biliares: como prevenir. Arq Bras Cir Dig 2010; 23(4):215-216. ^{, 6}6. Fathy O et al. Post-cholecystectomy biliary injuries: one Center experience. Hepatol Gastroenterol 2011;58:719-724. ^{, 12}12. Linhares BL, Magalhães AG e Soares PM. Lesão iatrogênica de via biliar pós-colecistectomia. Rev Col Bras Cir 2011;38(2):95-99..

Given the learning curve for new surgeons and the presence of a higher incidence of iatrogenic lesions of the bile ducts, the aim of this study was to analyze comparatively the two standard procedures for cholecystectomy - laparotomy and laparoscopy - in order to verify the iatrogenic injuries they may cause.

METHODS

A retrospective cohort study was performed with analysis of charts of the Department of General Surgery, Hospital Ipiranga UGA - II, São Paulo, SP, Brazil. All patients that underwent laparotomic and laparoscopic cholecystectomies from 01/01/2010 to 31/12/2011 were analyzed. The only criterion for inclusion was to be operative bile duct injury, regardless of location or time of diagnosis. There were no exclusion criteria. Information on gender, age, acute or chronic symptoms, type of operation, time of diagnosis of the lesion and its location were evaluated. All patients underwent general anesthesia and operated by residents of the second year of general surgery, guided by assistant surgeons or preceptors.

RESULTS

A total of 515 patients with cholelithiasis, diagnosed by clinical and imaging examination, were operated being 320 (62.1%) by laparotomy and 195 (37,9%) by laparoscopy. The age of patients with bile duct injury ranged from 29 to 70 years (mean 49.2). Among those who underwent laparotomy cholecystectomy, four cases were diagnosed (1.25 %) with lesions of the biliary tract, corresponding to 0.77 % of the total patients. No patient had iatrogenic interventions with laparoscopic surgery (Table 1).

The lesions were diagnosed intra- and postoperatively. The ones recognized intraoperatively had: one injury to the right hepatic duct and one cystic duct avulsion; later, two cases with stenosis of the common bile duct in 17 and 41 days postoperatively diagnosis done by endoscopic retrograde cholangiopancreatography. In one of these cases there was reference to accessory bile duct ligation, while in the other no mention of complication during surgery was written.

Three cases (75 %) of bile duct injury were symptomatic at the time of re - admission and were operated by emergency general surgery service and a case was electively treated at the same service, who died from complications of the biliary injury. No biliary lesions were diagnosed in 195 patients (37.9 %) undergoing laparoscopic cholecystectomy.

DISCUSSION

Cholecystectomy is the most common elective abdominal operation in the world and its iatrogenic injury is the most feared complication. The incidence of this lesion is about one for every 800 procedures⁶6. Fathy O et al. Post-cholecystectomy biliary injuries: one Center experience. Hepatol Gastroenterol 2011;58:719-724. ^{, 14}14. Milcent M, Santos EG e Bravo GP. Lesão iatrogênica da via biliar principal em colecistectomia videolaparoscópica. Rer Col Bras Cir 2005;(6):332-336.. After the introduction of laparoscopic surgery, indicated as the gold standard in the treatment of cholecystitis, the incidence increased to one in 120 procedures, significant increase, due to the technical difficulty and learning curve of the procedure, according to most authors⁷7. Garden CS. Lesão iatrogênica da via biliar e videocirurgia. British J Surg 2006; 93:158-168. ^{, 9}9. Jablonska B and Lampe P. Iatrogenic bile duct injuries: etiology, diagnosis and management. World J Gastroenterol 2009;15(33):4097-4104. ^{, 14}14. Milcent M, Santos EG e Bravo GP. Lesão iatrogênica da via biliar principal em colecistectomia videolaparoscópica. Rer Col Bras Cir 2005;(6):332-336..

The present study demonstrated rate of bile duct injury in 0.77% of cases, all underwent laparotomy cholecystectomy (1.25%). The incidence reported in the literature varies between 0.1-0.5% for this access, and 0.07 to 0.95 % for laparoscopic cholecystectomy. In this study there was no bile duct injury with laparoscopic surgery.

Several factors are implicated in the pathogenesis of bile duct injury as male gender, acute cholecystitis, surgical approach and anatomical variation; the latter, is the responsible for the majority of technical difficulty of cholecystectomy. The anatomical variation is reported present between 6-25% of patients with bile duct injury. The most common anomaly is an aberrant right hepatic duct in hepatobiliary triangle (Calot) ⁶6. Fathy O et al. Post-cholecystectomy biliary injuries: one Center experience. Hepatol Gastroenterol 2011;58:719-724. ^{, 10}10. Lau WY and Lai ECH. Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int 2007;6:459-463. ^{, 16}16. Santibánes E, Ardiles V and Pekolj J. Complex bile duct injuries: management. HPB 2008;10:4-12..

Early identification of biliary injury is of fundamental importance for the treatment; however, it is only diagnosed in less than half of the cases. This fact results in severe late complications such as biliary cirrhosis, liver failure and death. One case in this series died from complications of bile duct injury.

Among various existing classifications for injury to the bile duct stands out Bismuth´s one (1982)⁷7. Garden CS. Lesão iatrogênica da via biliar e videocirurgia. British J Surg 2006; 93:158-168. ^{, 12}12. Linhares BL, Magalhães AG e Soares PM. Lesão iatrogênica de via biliar pós-colecistectomia. Rev Col Bras Cir 2011;38(2):95-99., more used in late stenosis mainly as consequence to thermal injury or bile duct ligature commonly associated with local/regional inflammatory reaction. The bad medical records and late re-intervention difficult classification in this case series⁵5. Crema E. Lesões iatrogênicas da vias biliares: como prevenir. Arq Bras Cir Dig 2010; 23(4):215-216. ^{, 18}18. Wu JS, Peng C, Mao XH and Lv P. Bile duct injuries associated with laparoscopic and open cholecystectomy: sixteen-year experience. World J Gastroenterol 2007;13(16):2374-2378..

The first goal in treatment is sepsis and bile leak control. Surgical reconstruction after resolution of the initial sepsis is not urgent and can be done a few weeks posteriorly.

Roux-en-Y hepaticojejunostomy is the best treatment option and more often employed. Another form of treatment is the use interventional radiology placing T (Kehr) device in minor injuries, followed by dilation or placement of endo- prosthesis⁴4. Connor S and Garden J. Bile duct injury in the era of laparoscopic cholecystectomy. British J Surg 2006;93:158-168. ^{, 9}9. Jablonska B and Lampe P. Iatrogenic bile duct injuries: etiology, diagnosis and management. World J Gastroenterol 2009;15(33):4097-4104. ^{, 20}20. De Wit LT, Raws AJ, Gouma DJ. Surgical management of bile duct injury. Scand J Gastroenterol. 1999;34(Suppl 230):89-94..

Clearly the experience of the surgeon reduces the incidence of early and late complications of biliary tract injuries, both in open or in laparoscopic approaches.

CONCLUSION

Laparoscopic cholecystectomy compared to laparotomy cholecystectomy had a lower rate of bile duct injury.

REFERENCES

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