BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;management and prevention When bad things happen to good surgeons fiazfazili skims may262012
Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention--do no more harm-have low threshold for conversion;call for help of seniors or expertise or refer to higher center
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BILE DUCT INJURY DURING LAPAROSCOPIC cholecystectomy- causes-detection;management and prevention When bad things happen to good surgeons fiazfazili skims may262012
1. Masjid Nabawi –dream destination for
any Believer
ن ّ وملئكت يصل ن عل نبي ي َيه لذ ن
َ إِ ّ ا َ َ َ َ ِ َ َه ُ ُ َّو َ َ َى ال ّ ِ ّ َا أ ّ َا اّ ِي
ل
آ َ ُوا َّوا َ َيْ ِ َ َّ ُوا َسِْيم
من صل عل ه وسلم ت ل
“yeh bargahi habib haq hai-chalo saroon ko jhuka jhuka kar -durood har ik qadam pai
bejoo-niyazemandi dikha dikha kr”
3. Strategies for Lowering the Rate of Bile Duct
Injuries in Laparoscopic Cholecystectomy
bile duct injuries
A Review --M echanism , Preventive M easures, and Approach
to M anagem ent:;;Repair
When BAD THINGS HAPPEN TO GOOD
SURGEONS ? Why? …where?...who?
part1
•Quality Manager and Supervisor CME Surgery .
•Group leader ---JCI joint commission international for Hospital accreditation
Surgical chapter
•Editor ( Ass ; Rev ; Online ) international and Medical Journal - Minimal
access ,;
•. slidedworld . com ; ind jr of surgery
•–Literature review current through:. This topic last updated Feb 2012
Literature review current through: Feb 2012.
DR;FIAZ FAZILI –
This topic last updated: Jun 8, 2010
4. Congressman: Murtha Died
After Intestine Was
Damaged in Gall bladder
Surgery
Rep. John Murtha (D-PA), the
first veteran of the Vietnam war
to be elected to Congress and
one of its most powerful
lawmakers, died Monday
afternoon at Virginia Hospital
Center in Arlington, Va., after
complications from gallbladder
surgery.
The gallbladder surgery was
performed days earlier at the
National Naval Medical Center
in Bethesda, Md
5.
6. Present status of Post lap chole-biliary duct injuries-
A Quality Manager’s overview…
How can we improve? Debatable—Controversies & issues (policy)
. ARE WE Practicing –Safe surgery rules ?
.
h Who is doing What ,at What place ;and on Whom?...
t Is BDI following lap chole –prof negligence (Medical
malpractice) or risk inherant to procedure
7. َ َ ِ ْ َ َ َا ِن َآّ ٍۢ ِى ٱ
لْرض ول و م م د بة ف
طَ ئر يط ر بجن ح ه إل أمم
ٌ َ ُ ّٓ ِ ِ َْٓ ِ ٍۢ َ ِي ُ ِ َ َا َي
كتَب
ِ َ ِ َْمْ َا ُ ُم ۚ ّا َ ّطْ َا ِى ٱل
أ ث لك م فر ن ف
ِْن َىْ ٍۢ ۚ ُ ّ َِىَ َّ ِم
م ش ء ثم إل ر به
ي شر ن
َ ُحْ َ ُو
The Noble Quran- Al-
Anam (6:38)-
There is not a moving (living)
creature on earth, nor a bird
that flies with its two wings,
but are communities like
you. We have neglected
nothing in the Book, then
unto their Lord they (all)
shall be gathered.
8. ollaboration among Surgeons, Gastroenterologists and
interventional Radiologists is imperative in the management of
such injuries
9. A good story during the incidents, the
explosion of a plant in Nanjing, China on July
28, 2010 . Event of a crash that killed 13
people and injured 300 people tells a lot of
attention the fact that suck the public.
During the explosion occurred, a monkey was
recorded during the camera saves the puppy
from the explosion site. They hold the dog as
he ran out of the factory.
If this event can tap our collective conscience,
animals can show compassion and kindness to
each other.
Gensis powerful high explosive that occurs
when a pipe from burning chemical factory in
China. The explosions occurred in Nanjing,
Jiangsu provincial capital, about 10.00 am. In
addition to deaths and injuries, the explosion
also damaged the surrounding area. windows
of houses, shops and offices were damaged
and affect the extent to 300 meters. While
other people thought was an earthquake.
10. Case 1
A 55 years old male Yemeni. Had post-
cholecystectomy CBD injury.;Detected post
operative period ;Surgeon referred to Gastro
enterologist/.Dr.Fk,for evaluation /
management, from ,,,,,,,,(……. Hospital)
Dr. FK referred the patient for US esp-
Heaptobiliary area.Then he performed the
First ERCP for the Patient, in 9/12/2006
19. ERCP and Radiology Imaging and Interventional
management of Peri op complication of Lap chole
are an effective Diagnostic and Therapeutic
modality. A great relief and help ..lap surgeon
The technical skill, experienced hand and good
knowledge of the different procedures are required
to increase success and limit complication rate.
20.
21. “we [general surgeons]
had already lost
traditional surgical fields
like polypectomy,
papillotomy, and now
even endoscopic
appendectomy .
I was convinced that if
we passed up this
chance like endoscopic
cholecystectomy,
internists and
gynecologists would
again take away a piece
of our
competence….”Muhe
22. Picture of the abdomen of the first patient to have
laparoscopic cholecystectomy, September 12, 1985, showing
portholes in the lower abdomen.
23. Basic pistol grip hemoclip applier and scissors made for W.
Reynolds, Jr, MD, in 1972.
24. Mühe's open tube
laparoscopic
cholecystectomy,
Technique No. 2.
Patient with 1 access,
directly above the gall-
bladder without
pneumoperitoneum
because the costal
arch is a firm bone
roof.
25. The spectrum of mishap has also
changed due to the involvement of
new instruments/technique such as;
stapling device,hook scissors; & energized
instruments
New Complications like; migrating clips
or spillage of gallstone;thermal
injurues into peritoneal cavity were
completely unknown in open surgery.
26. Surgeons rushed in massive numbers to learn the surgery, taking weekend courses—to
add laparoscopic surgeon to their business boards. ;prescription pads
27. 1992 NIH safety approval Lap chole ----- An increase
from 0.1% to about 0.6% -5%(x10 times)
WERE been noted ;
As of 2012, 0.4%..(OC—0.1-0.3% ).
Expected drop in % significantly with
---time/experience.but…it didn’t happen
Between 34% and 49% of surgeons are
susceptible (expected to )cause such an
injury during their career.
28. It was a plausible and logical argument that the
abrupt rise in bile duct inj uries associated with the
earliest efforts to perform laparoscopic
cholecystectomy could be expected to drop
significantly once surgeons and residents
progressed beyond their own learning curve for this
novel technique.
30. Certainly, it has not been for a lack of research on laparoscopic
cholecystectomy. A Medline review found more than 20000 articles
published on the subject in 2001 alone. Perhaps processes in play,
unrecognized by surgeons, have prevented us from making progress in our
efforts against the learning curve.
31.
32. a) Doing the right thing right the first time only.
b) Doing the right thing right the next time.
c) Doing the right thing right the first time, doing it
better the next time---in all time.
d) All of the above
The answer is====C-Doing the right thing right the
first time, doing it better the next time---in all time.
.)
39. To improve our results, we need to
accurately identify the cause of our
mistakes-
Suggest RECOMMENDATIONS-..To apply human
performance concepts in an attempt to understand the
causes of and to prevent laparoscopic bile duct injury
40.
41. Level I Evidence from properly conducted randomized, controlled trials
Level Evidence from controlled trials without randomization-Or
II Cohort or case-control studies Or
Multiple time series, dramatic uncontrolled experiments
Level Descriptive case series, opinions of expert panels
III
Scale Used for Recommendation
Grading
Based on high-level (level I or II), well-performed studies with uniform
Grade A
interpretation and conclusions by the expert panel
Based on high-level, well-performed studies with varying interpretation and
Grade B
conclusions by the expert panel
Based on lower level evidence (level II or less) with inconsistent findings and/
Grade C
or varying interpretations or conclusions by the expert panel
42. Policy and procedures--
Who should do what ?
Do we need to certify or
accredit,any hospital or
pvt nursing homes before
allowing them to…..lap
surgery????
In case of bdi—is there
any written PROTOCOL,
Arrangement
Do we need supervising body
of experts….for every splty for
monitoring.?
43. Safe surgeon
To this day, there are a lot of doctors performing this surgery
who should not be performing the surgery because they are
not qualified
Should we allow every one to do lap surgery -Who is so
called a ,”GoodSurgeon?”
What are basic requirements to allow lap chole to be done
by any Surgeon for any set up ?
44.
45. "A good surgeon knows how to Reasonable knowledge
operate of Anatomy and fair use
A better surgeon knows when to of Instruments
operate
The best surgeon knows when not to
operate"
Qualified Certified for Open surgery
Accreditations-laparoscopy recognized center
Low threshold for conversion to open
Doesn’t hesitate to call for second opinion-transfer
to higher center
DO NO MORE HARM?-Respect s tissues- --Respect
tust Doesn’t hesitate to call for second opinion-
transfer to higher centerpatient rights.
46. There is increased rate of cholecystectomies after laparoscopic era?
Are we operating on right kind of patients or we have conflict in our interest ?
To operate or not to operate …on asymptomatic gall stone pts.
47. Indications Contraindications-
“Most patients with symptomatic Relative contra-indications
gallstones are candidates for lap for laparoscopic biliary
chole, ". Fit fr g/a; no tract surgery
comorbidities
Untreated coagulopathy, l
biliary dyskinesia,
ack of equipment,
acute cholecystitis, (calcukar
lack of surgeon expertise,
or acalcular );
hostile abdomen,
Complications related To
CBD stones including ؛ advanced cirrhosis/liver
Pancreatitis failure, and
Suspected gallbladder
cancer.
Ebm=(Level II, Grade A). Eivdence =(Level II,
Grade A).
48. Asymptomatic
Did you know?
Majority of people with
gallstones: Should we
gallstones never experience operate?
any symptoms. TO OPERATE OR
Others remain aysmptomatic (without
symptoms) for at least 2 yrs s after the NOT TO OPERATE ON
stone formation begins.
????Is there also a financial motivation that
ASYMPTOMATIC
If symptoms do occur, the chance of
GALLSTONES IN
attracts surgeons to this minimally invasive
developing pain is about 2% per year
for the firstprocedurethe stone LAPAROSCOPY ERA
10 yrs after (including a lot of gallbladder removal
formation, after which the chancepatients www.wals.org.uk/article.htm
procedures for for that did not deserve
developing symptoms decrease. removal ?
(Review article).
Risk of bile duct injury with DR Fiaz Maqbool Fazili.
laparoscopic cholecystectomy is #Asymptomatic gall stones
around 0.2%
do not require treatment.
(excp high risk grp)
49. 11:6
There is no moving creature on
earth but its sustenance dependeth
on Allah: He knoweth the time and
place of its definite abode and its
temporary deposit: All is in a clear
Record.
(52:58
"Surely Allah is the
Bestower of provision,
Lord of Power, the
Almighty".,)
50. Is the Main problem misperception of ductal anatomy—or Surgeon
related(“)Attitude of Surgeon”?
51. Risk Factors
◦ Anatomical
◦ Anatomical variations (biliary and vasculature)
◦ Bleeding, scarring, obesity
◦ Laparoscopic inherent-
◦ Lack of Depth Perception, Tactile Feedback, Full Manual
Maneuverability—working on image
◦ Improper surgical approach –Improper Lateral retraction (insufficient or
excessive)
◦ 0 degree scope
◦ Approach plane too deep-too close to CBD-duodenum
◦ ATTITUDE__not sticking to rules of game.
◦ Lack of conversion to OC during difficult cases;
◦ Between 34% and 49% of surgeons are expected to cause such an
injury during their career.
52. Video assisted Lap -Operation is on image-lack
of tactile sensation,contrast and depth of
vision –(integrity of eye ;brain; tactile )
No camera X megapixels and chips can
replace human eye--
“so which of yourLord's bounties will you
two deny?Holy quran Ch AL – RAHMAN )
53.
54. In the open approach, Standard exposure
the gallbladder and provided by laparoscopy
the biliary tree are distorts the normal
viewed from the top alignment of the
down, whereas in structures by laterally
laparoscopy the biliary retracting the gallbladder
structures are viewed and creating an angle in
head on- the common hepatic duct
(CHD)/common bile duct
(CBD).
57. Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm
with common hepatic duct (15-25%); F,G,H. Medial cystic duct insertion
(10-17%). Uncommon variants: C. High fusion with hepatic duct; D. Fusion at
right hepatic duct; F. No cystic duct.
58. Refers to common hepatic duct obstruction caused by
an extrinsic compression from an impacted stone in
the cystic duct
Estimated to occur in 0.7-1.4% of all
cholecystectomies
Often not recognized preoperatively, which can lead to
significant morbidity and biliary injury, particularly
with laparoscopic surgery
59. The safety of
laparoscopic
cholecystectomy
requires correct
identification of
relevant anatomy.
(Level I, Grade A).
Intraoperative
cholangiogram may reduce
the rate or severity of
injury and improve injury
recognition. (Level II,
Critical view of safety
Grade B).
60. In the 1990s , high rate( 2% -5%) of biliary injury was
due in part to learning curve effect.
A surgeon had a 1.7% chance of a bile duct injury
occurring in the first case and a 0.17% chance of a
bile duct injury at the 50th case.
Conflicting with above reports-
@However most surgeons passed through learning
curve, “steady-state” reached , but there has been no
significant improvement in the incidence of biliary
duct injuries.
Moore M.J.; Bennett C.L , The American journal of surgery 1995
@Mubasher H Khan et al Gastrointest Endosc 2007
61. .
Excessive traction leading to tenting of the CBD is
another factor predisposing to clipping and ligation of
the bile duct, especially when performing an open
cholecystectomy.. Obesity and excessive fat in the
porta hepatic area also poses technical difficulties
and can predispose to bile duct injuries. [9]
63. Cephala
The
faulty
d
traction
The common bile duct
techniq
ue of
on GB to
tent the
is mistaken for the
retracti CBD out
of
cystic duct and
on puts
you
normal
location,
transected. A variable
into
positio
leading
to clip
extent of the
n of
mistaki
placeme
nt at the
extrahepatic biliary
ng cbd cystic
duct-CBD
tree is resected with
for
cystic
junction
the gallbladder.
duct
Bdi
Correct traction
64. --Mistaking the common
bile duct for the cystic duct
Pulling forcefully/ duct-Cephalad traction up on
the GB when clipping the cystic duct tenting
injury to the junction of the CBD & common
hepatic. Duct.to
65. Inappropriate use of
electrocautery near or
around the CBD may
damage its axial blood
flow, leading to ischemic
damage to the duct and
late stricture formation
Thermal necrosisductal
tissue loss
May lead to bile leaks or
delayed stricture
Mechanical trauma can
have similar effects
66. Local risk factors ; 15–35% of BDI
Bleeding in Calot’s triangle, Severely Scarred or shrunken gall
bladder,. ;Inflammation -; Mirizzi’s syndrome ;Large impacted
gallstone in Hartmann’s pouch, Short cystic duct, Acute
cholecystitis, Acute biliary pancreatitis
Abnormal biliary anatomy].
Lack of Experience or overconfidence+++
More than ½ (half) of all such injuries occurred during the so
called “easy” LC performed by an inexperienced surgeon . ]
Male sex and prolonged surgery~ for more than 120
minutes -independent risk factors
67. Can we minimize it ?
—what are modifiable factors-?
Pt related –no ;
Equipment-Environment –(some minimum requirements)
Surgeon related—attitude-technique –-credentialing-
revalidation
RULES OF THUMB TO
HELP PREVENT BILE
DUCT INJURIES
69. Adequate and proper training in a laparoscopic surgery,
delineation of biliary anatomy in Calot's triangle (critical view)
by careful surgical dissection, .
if need be by intra-operative cholangiography (IOC), in difficult
cases ,
Avoiding blind application of clips, cautery in case of bleeding
in the Calot’s triangle are some of the measures to avoid a BDI
judicious use of electrocautery,
The primary cause of error was visual perceptual illusion in
97% of the cases . Fault in technical skill was present in only
3% of injuries.
[Br J surg and Am j surg 2005.2008).
70. Attention to operative details (insufficient close or
deep plane)
Stasberg’s critical view of safety
Appropriate Handling of Gallbladder
Careful use of diathermy
Recognition of Biliary and Vasculature Anomalies
71. Dissection within
the triangle of
Calot to
demonstrate the
cystic duct and
artery clearly
entering the GB
Critical view of safety
72. Surgeons with more experience have the lowest
complication rates
Furthermore, credentialing for laparoscopic surgery is
now becoming a reality.
Many institutions currently, or soon, will require proof of a
fundamental skill-set in basic laparoscopy for
credentialing purposes.
(SAGES) have developed a validated assessment tool
named Fundamentals in Laparoscopic Surgery (FLS)].
FLS is now required by the American Board of Surgery to
qualify for the surgical certification examination.
74. IOC - may reduce the rate or severity of injury
and improve injury recognition. when used
routinely and allows access to the biliary tree
for therapeutic intervention; (Level II, Grade B).
• Routine IOC is technically challenging, adds cost and time
to the procedure & is unnecessary for the majority of
patients—
• Laparoscopic cholecystectomy without cholangiography: Is it a
safe procedure?
• O M Elhassan and F M Fazili Minim Invasive Ther 4(4):219 - 222 (1995)
•
• Few Surgeons selectively use preoperative (ERCP) and
perform IOC based on abnormal LFT or a dilated CBD
or /on preoperative USG.
75. Intraoperative
cholangiogram shows
filling of distal bile duct
with flow into the
duodenum. The lack of
retrograde flow into the
proximal biliary tree is
concerning. A clip may
be present occluding the
bile duct proximally.
76.
77.
78. Dome down technique-- Dissection of the
gallbladder from the liver bed:The more
conventional approach starting at the
gallbladder infundibulum and working
superiorly, or the top down approach, may be
used with electrocautery, ultrasonic
dissection, or hydrodissection as the surgeon
prefers.
Level II, Grade B).
Percutaneous and open cholecystostomy
Partial cholecystectomy
CONVERSION TO OPEN
79. Conversion should not be
considered a complication and
surgeons should have a low
threshold for conversion;
Decision to convert to an open
procedure must be based on
intraoperative assessment
weighing the clarity of the anatomy
& the surgeon’s skill/comfort in
proceeding.
80. Use of the checklist reduced the rate of deaths and
complications by more than 1/3 across all 8 pilot
hospitals. (Canada;India; Jordan;;NZ;;Philiphine ;Tnazania; Uk; ;USA)
The rate of major inpatient complications dropped from
11% to 7% after implementation of the checklist. at
essentially no cost to the system..
83. Type A ;Cystic duct leaks
or leaks from small ducts
in the liver bed
Type B ;Occlusion of a
part of the biliary tree,
almost invariably the
aberrant right hepatic
ducts
Type C; Transection
without ligation of the
aberrant right hepatic
ducts
Type D; Lateral injuries to
major bile ducts
Type E ;Subdivided as per
Bismuth classification into
E1 to E5
84. E: injury to main
duct (Bismuth)
E1 : Transection
>2cm from
confluence
E2 : Transection
<2cm from
confluence
E3 : Transection in
hilum
E4 : Seperation of
major ducts in hilum
E5: Type C plus injury
in hilum
87. Bile Duct Injuries
• How do you get Suspicion DURING OR—(intra
operatively)
• Atypical anatomy
• “Accessory” duct
• Unsuspected bile leakage
• Abnormal cholangiogram
88. Only 25-33% of injures are recognized intraoperatively
1. Expertise available ; Convert to Open Procedure and
perform Cholangiography or vice versa (determine extent of
injury) and accordingly --treat
2. Experitise not available ;Perform the cholangiogram
laparoscopically with intent of referring patient (placement
of drains);
1. Consult an experienced Hepatobiliary surgeon;
2. Quicker the repair, the better the outcome!!!
Acute Management-do no more harm----Drain the bile- Sepsis
control
Biliary catheter for decompression of biliary tract & Control of bile
leaks
Percutaneous drainage (US/CT) of intraperitoneal bile collection
89.
90. The classic injury is when the CBD is mistaken for the
cystic duct. Once the gallbladder has been removed, it is
important to recognize that more than one
structure has been injured, and the repair is
complex.
The goal of reconstruction is to avoid cholangitis, cirrhosis
and stricture.
In the presence of an injury, it is important not to panic,
leave the patient well drained to control the
leak, and refer to an experienced hepatobiliary
surgeon.
Finally, if an injury should occur, an experienced
hepatobiliary surgeon should make the repair;
this will greatly impact the rate of complications and the
long-term success of the repair.
Timing-- Data suggest that repairs performed early or
after six weeks of the injury have better outcomes
91. Patient presents with…clinically
Vague abdominal pain, nausea, fever, jaundice, vomiting
Investigation
Blood –lft.cbc;kft
Ultrasonagraphy and CT (ductal dilatation and intra-abdominal
collection)
Cholangiogram
ERCP—biliary anatomy and assess the injury
PTC—define biliary anatomy proximal to injury
MRCP—noninvasive (can miss minor leaks)
HIDA scan--
MR angiography—vascular injuries
92. HIDA – presence of
active bile leak
(physiologic
94. Provides exact anatomical diagnosis of bile duct leak;
while allowing treatment w/ decompression of the
biliary tree.
Principal of treatment is to establish a pressure
gradient that will favor flow into the duodenum not
the leak site; may entail removal of retained stone or
internal stenting +/- sphincterotomy
Internal stenting is currently the procedure of choice
for treating bile duct leaks ( types A & D)
Cessation of bile extravasation in 70-95% of cases
w/in 7 days
95. POST-OPERATIVE BILE LEAKS &
BILIARY FISTULAS
Limitations of ERCP—PTC –MRCP superior but non therupetic
Inability to visualise the biliary tree beyond the obstruction
Bilomas might need percutaneous drainage
PTC
96. POST-Lap chole
BILE LEAKS & BILIARY
FISTULAS : ROLE OF ERCP=good
gastroenterologist is a help
;
Fazal Khawaja,
-
Gastroenterology
King Fahad Hospital
Al Madina Al Munawarah.
97. Our experience (15yrs)
Lap – Chole Related Bile leaks:
Cystic duct stump 27(40%)
Duct of Lushka 8(12%)
Main Bile duct ( no luminal
narrowing or obstruction) 5(7.5%)
With main Bile duct injury 8(12%0
(convert to open = 6)
MBD Inj + no leakage in ERC 19(28%)
Total=67/171
98. ERCP helps in diagnosis and removes any doubts regarding possible major ductal injuries.
The condition resolves spontaneously ] provided there is no distal obstruction; the process
may be hastened by the placement of a stent endoscopically.
101. Careful flouroscopic observation of leakage point of origin
An un-experienced & poorly equiped Endoscopist is the
surgeons worst enemy
To have a complication is bad luck but to mismanage it is
Bad Medicine
102. Figure 2: MRCP revealing subhepatic and
significant intra-abdominal bile collection from
cystic duct leak. The CBD is not dilated. The
patient was managed effectively with ERCP
Figure 1: ERCP showing small CBD leak managed sphincterotomy.
effectively by sphincterotomy
103. POST-OPERATIVE BILE LEAKS &
BILIARY FISTULAS
Limitations of PTC and ERCP
Inability to visualise the biliary tree beyond the obstruction
MRCp is diagnostic-shows both ends but is not therupetic
Bilomas might need percutaneous drainage
ptc
104.
105. examine the source of bile leak
Although bile may leak from an opening in the GB or the cystic
duct, before that is presumed to be the case, BDI should be
ruled out. Bile from GB is greenish yellow, thick, and viscid,
whereas common bile duct (CBD) bile usually is bright yellow,
thin, and watery.
An IOC at this stage may delineate the anatomy and prevent
any further injury to the bile duct.
A BDI should also be suspected if a third tubular structure
(after cystic duct and artery have been clipped and divided) is
encountered in the Calot’s triangle. The “cystic duct” which was
clipped and divided earlier may actually have been the CBD
and the third structure now being encountered may be the
common hepatic duct.
If the BDI is recognized intraoperatively, the management
depends on the nature of the duct injured, type of injury, and
the expertise and experience of the surgeon
107. The goal of surgical repair of the injured biliary tract is
the restoration of a durable bile conduit, and the
prevention of short- and long-term complications such
as biliary fistula, intra-abdominal abscess, biliary
stricture, recurrent cholangitis and secondary biliary
cirrhosis.
The ease of management, operative risk, and
outcome of bile duct injuries vary considerably and
are highly dependent on the type of injury and its
location. For this, a classification bearing therapeutic
and prognostic implications is needed.
108. Controlling sepsis, establish biliary drainage, postulate
diagnosis, type and extent of the bile duct injury.
Broad-spectrum antibiotics
No need for an urgent laparotomy. Biliary reconstruction in the
presence of peritonitis results a statistically worse outcome in
patients.
No need for urgent with reconstruction of the biliary tree. The
inflammation, scar formation and development of fibrosis take
several weeks to subside.
Reconstruction of the biliary tract is best performed electively
after an interval of at least 6 to 8 weeks.
111. Injury to a major duct (right hepatic
duct/CHD or CBD) has more serious consequences. In
the event of this unfortunate incidence, further
management including assessment would depend on
the availability of expertise
. Expertise Available
In an ideal situation, a trained biliary
surgeon with adequate experience in reconstructive
biliary surgery should carry out the repair. The
procedure should be converted to an open operation,
and the injury should be repaired as detailed
subsequently.
112. A lateral/incomplete injury (involving partial
circumference of the duct) may be repaired with fine
(4-0/5-0) suture of vicryl/PDS. Some recommend the
placement of a T tube as a stent.
However, the placement of a T tube in an undilated
normal size duct may be difficult and frustrating and
could potentially aggravate the injury
113.
114.
115. If the duct has been divided,
it is important to assess if there is associated loss of
a segment of the duct as happens in the classical
lap cholecystectomy injury
This happens when the CBD is first clipped and
divided mistaking it for the cystic duct. CHD is then
encountered and divided again.
The ideal management of a complete
transection of the bile duct is the restoration of the
biliary enteric continuity with a Roux-en-Y
hepaticojejunostomy
.
116. When the bile duct has been divided without excision of
a segment, a primary end to end anastomosis of the cut
ends of bile duct has been described. This procedure
had fallen into disrepute after a report stating that
almost half of such repairs developed into strictures that
later required hepaticojejunostomy.
. A distinct advantage of this procedure is that it
maintains the normal biliary drainage into the
duodenum and avoids the risk of reflux associated
cholangitis and stricture following hepaticojejunostomy.
Another advantage of the repair is that the stricture that
might result is usually of a low variety (Bismuth Type 1
or 11). These are more easily repaired surgically in the
event of failure of endoscopic and radiological
intervention
117. in such situations no attempt must be made to repair the injury. Repairs
done by inexperienced surgeons are likely to fail.
In addition, repair after a previous attempt even if done by an expert biliary
surgeon is less likely to be successful
The safest option (in the interest of both the patient and surgeon) is to
irrigate the area with copious amounts of solution, observe and record the
operative findings and place two large/wide bore (28 French) drain in the
subhepatic fossa [
This will drain the bile from the injured duct and prevent the formation of a
bilioma. Omentum if available may also be placed in the subhepatic fossa.
This can be accomplished laparoscopically and there should be no need to
convert to laparotomy. This will result in a controlled external biliary fistula,
thus preventing peritoneal sepsis .
Postoperatively an endoscopic papillotomy may be performed and a stent
placed in the CBD in cases of partial injury to decompress the bile ducts
The external biliary fistula may eventually close without any biliary
obstruction in case of partial injury. In some cases especially those with
complete injury, the biliary fistula may not close and repair will need to be
performed using the undilated proximal ducts
118. In the majority of cases (more than 60%), the biliary injury is unrecognized
at laparoscopic cholecystectomy
A high index of suspicion is essential to recognize biliary injury (leak or
transaction of CBD) in the early postoperative period.
the most common site of leak included cystic duct stump (78%), a
peripheral right hepatic duct (Luschka 13%), and other sites like common
bile duct and T tube insertion point (9%) [In a study of 2007 post ercp)
The leak could either be low grade (LG) where the leak is noted only after
the opacification of the intrahepatic biliary radicles with contrast following
ERCP or a high-grade leak (HG) when the leak is observed fluoroscopically
before intrahepatic duct opacification [
The later is considered more significant as the spillage of contrast occurs
with minimal injection pressure and before the opacification of the ductal
system. Patients with LG leak are effectively managed by sphincterotomy
alone or placement of nasobiliary tube or stent placement, and it could
achieve reduction in pressure gradient and allow closure of leak in >90%
HG leak however would require stent placement with probably bridging the
site of leak-like cystic duct stump leak. Decision of stent placement is
however determined by the severity of leak rather than site of leak [12].
119. If there is no bile leak, the patients may not have any
symptoms and signs in the early postoperative period and
may develop jaundice after an uneventful discharge from
the hospital.
Therefore, a follow-up visit approximately 1 to 2 weeks
after cholecystectomy is desirable. Some BDIs especially
ischaemic may present several months or even years after
cholecystectomy .
The management of injury detected after discharge from
the hospital should be performed at a center with
appropriate expertise outlined previously.
The procedure of choice for repair of a major
duct injury or stricture is a hepaticojejunostomy [.
120. More often a biliary stricture develops (with dilated proximal
ducts) which will require a hepaticojejunostomy. Placement of
a tube into the proximal end of the divided duct to convert the
BDI into a controlled external biliary fistula is attempted by
some. The attempt to place a catheter into the injured
nondilated proximal duct during the course of a laparoscopic
cholecystectomy may, however, cause further injury to the
CHD, particularly when performed by an inexperienced
surgeon.
Clipping of the divided duct is sometimes performed with
intent to prevent bile leak and allow the injured duct to
stricture resulting in the proximal duct dilatation which
facilitates a hepaticojejunostomy .
This is rarely successful because in the majority of cases the
clipped or ligated ducts sloughs, thus causing the inevitable
bile leak and resulting in the injury becoming even more
proximal. Moreover, the clip (or ligature) also interferes with the
blood supply and causes ischaemic injury
121. Hepaticojejunostomy is preferred to choledochoduodenostomy as
the latter is prone for complications due to reflux cholangitis [ref 5, 9,
33].
Hepaticojejunostomy with Roux-en-Y anastomosis reduces the
tension of anastomosis and provides good blood supply and is the
preferred option to treat duct transection injury [5, 9, 26–28, 33].
It is also the procedure of choice to treat duct defect and strictures.
The outcome is significantly influenced by the surgical technique
especially when the duct is not dilated [27, 28].
The outcome is better when one layer end to end anastomosis with
5-0 absorbable suture is carried out with the loop for bile drainage
longer than 50cms to avoid reflux and infection [5, 9, 26–28, 33].
The dead tissue at the end of the duct should be debrided [26, 28].
Some would place a temporary stent tube through the area of
reconstruction when the duct is small. The tube helps to perform the
anastomosis while permitting to perform cholangiography to check
in a week or so, and it may serve as a drain if the anastomosis is
temporarily leaking. The use of a transanastomotic stent is, however,
debatable [25, 26].
126. The best outcomes
Early repair (72 hours after LC-BDI)
late repair (>6 weeks after LC-BDI).
A minor comment is that an interval between 0 and 72 hours after LC-
BDI has an unclear meaning:
0 hours suggests intraoperative repair,
Most important, within the intermediate timing of repair (from 72 hours to 6 weeks
after LC-BDI), a critical distinction should be made between the presence of a clean
surgical field (ie, complete common bile duct stenosis with obstructive jaundice, without
bile spillage) and a field that is inflamed or infected by bile.
We believe that in the former case, surgical repair would occur in an ideal condition
within 2 weeks following LC-BDI, . .
127. EXPERT VS NORMAL ; Successf rate when Surgery performed by/at
Primary surgeon =35%
Specialized Expert( hepatobiliary surgeon)=>90 %, (John
Hopkins Group –99 )
Timing– of Repairs ;Early or after 6 weeks of the injury have
better outcomes than those repaired in the intermediate period.
Contirb factors for outcome- active peritonitis , assoctd vascular injury, the level
of injury at or above the biliary bifurcation, and no.of previous operations
128. Suggested flow diagram for patients with suspected bile duct injury
after laparoscopic cholecystectomy [3].
Manouras et al. Journal of Medical Case Reports 2009 3:44
doi:10.1186/1752-1947-3-44
129. Timing of diagnosis;Expertise availability; SEPSIS ETC
Endoscopic stenting for strictures
T-tube placement for minor lacerations
Primary duct-to-duct repair only if tension free anastomosis
available
Biliary anastomosis with jejunal loop for major excisional
injuries
131. An error during gallbladder surgery ) is a common source of
medical malpractice claims, largely because this is a common
form of surgery. Most malpractice claims from gallbladder
surgery occur when a surgeon does not know where the biliary
ducts are on a patient and cuts where the surgeon should not be
cutting.
Experience vs carelessness
Can an experienced surgeon using ordinary care cut this
common bile duct? The answer is almost certainly yes.
“it is the same surgeons who are “frequent flyers” in
malpractice claims involving common bile duct injuries.”-
malpractice lawyer
132. Another common defense is the “patient had unusual
anatomy” or “he/she was too fat to be able to see”
defenses. These are slightly more saleable defenses
in some cases but usually it is a reflex surgeons being
sued for malpractice use in every case.
Typically, there is nothing to suggest unusual anatomy
and no explanation as to why the doctor did not try to
use a cholangiogram (which malpractice cases rarely
involve) to figure out what belonged where.
133. Professional negligence is defined as absence of reasonable
care and skill or willful negligence of a medical practitioner in
the treatment of a patient, which causes bodily injury or death
of patient.
A doctor is not liable if he exercises reasonable skill and care,
provided that his judgment conforms to accepted medical
practice and does not result in an error of omission.
The doctor cannot be sued for professional negligence, when
statistics show that accepted methods of treatment have been
employed on the patient and that the risk and injury which
resulted are of a kind that may occur even though reasonable
care has been taken.
Present position----The usual misperception error
underlying laparoscopic bile duct injuries does not meet
the defining criteria of medical negligence
134. Bile duct injuries are a major complication of both open cholecystectomy
and LC. It can have devastating effects, turning the individual into a "biliary
cripple".
They mainly result from anatomical anomalies ‘local factors and errors of
human judgment and are thus preventable to some extent.
The costs are reduced and outcome improved if these injuries are
diagnosed early (during operation or the early postoperative period). And
handled by experienced biliary surgeon;Int rRadiologist
;;endoscopist (ERCP)Team)
Adding the experience gained from open cholecystectomy on the one hand
and the advantages of certification and revalidation in LC to improve
surgical techniques ;modifications in terms of visualization and
magnification on the other, will help in reducing the incidence of such
complications.
135. What model should exist in health
care?
It is argued that not one model
of accountability fits all of health
care.
Health care is too complicated,
with too many parties, with too
many complex relationships for
just one model.
Stratified model of
accountability? Tailored to local
conditions….
(Emanuel & Emanuel, 1995)
136. “ D e s p it e n u m e r o u s p u b lic a t io n s
o n t h is t o p ic , t h e r e is n o s im p le
QUOTE OF THE DAY
s e t o f r u le s t h a t in e x p e r ie n c e d
s u r g e o n s c a n f o llo w in o r d e r t o
a v o id s u c h a c o m p lic a t io n . W h e n
it c o m e s t o e x p e r ie n c e d
s u r g e o n s , w e a ll k n o w it is
h a r d t o t e a c h h u m ilit y . ”
Ist and last Message
=“first do no harm ”
-- e very student in medical school takes
137.
138. "There is no moving creature
on earth but its sustenance
depends on God: He knows
the time and place of its
definite abode and its
Temporary deposit: All is in a
clear Record"……… Qur'an,
Hud, 11: 6
The Bestower of Provision ,
Allah(SWT), the Almighty
says: "Surely Allah is the
Bestower of provision, Lord of
Power, the Almighty".Noble
Qur'an (52:58)
I am the Boss- I am the BEST –dnt know …
Why This arrogance?.....in this world ------
140. The author is indebited to those contributors whose
pictures have been shared with readers here for
purely academic purposes to benefit processionals
and patients(humanity at large ……..) and there is no
conflict of interest directly or indirectly except pure
academic reminders in bringing this material-to help
prevention of this complication ---and in case anyone
has his/her objection –the author will immediately
delete that ….material-- thanx
Hinweis der Redaktion
The place I work---The simplest definition of a health care error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient…
Surgeons have always analyzed their technical complications for insights that might be translated into improved performance.. An understanding of the root causes of technical complications are impt .. This presentation takes analysis of technical complications to greater depths, for it integrates the findings of videotapes of operations involving bile duct injuries, operative notes dictated after the operation had been completed but before an injury had become apparent, and conceptual tools of human factors research and the cognitive science of human error
How many people like Murthas might have died un reported-; un accountable –in places whhere there is no accountability or quality management like kashmir valley.
While LC offers the patient several advantages of minimal invasive surgery, the spectrum of complications in gallstone surgery has changed compared to open procedure. Laparoscopy-related complications such as bile duct injury (BDI) tend to be complex being more proximal and often associated with concomitant vascular injury [9]. This along with injuries during access into peritoneal cavity such as bowel and major retroperitoneal vascular injury has raised the morbidity to 2.9% [1–4]. The spectrum of mishap has also changed due to the involvement of new instruments such as stapling device and energized in struments. Related complications like migrating clips or spillage of gallstone into peritoneal cavity were completely unknown in open surger y. Surgical procedure used in the management of stricture include, Roux- en-Y hepaticojejunostomy, hepatectomy, and liver transplantation [3–6]. Recurrence of biliary stricture after a surgical repair can present many years later [5]. Therefore, these patients require long-term, may be life-long follow-up with hospital visits and investigations to detect recurrent stricture
Accountability is about individuals/orgamization/system- who are responsible for a set of activities and for explaining or answering for their actions . It is being “answerable” for something.It should be positive and premeditated. It emphasizes keeping agreements and performing tasks in a respectful manner.It is about learning, truth and continuous improvement. Accountability ranges from micro to macro… from personal to organizational to system to international.Without accountability, organizations are incapable of achieving and sustaining high performance. and -International patient safety goals .?; do we follow Accreditation policy;--Guidelines –policy procedures –protocols. Protocols for Allowing Procedure of Lap chole—Supervisory body –checks and balances. its most basic,
. POST LAP CHOLE CBD INJURIES = a serious and challenging surgical complication. Proper management requires a skilled and experienced he patobiliary surgical team.;interventional radiologist and Gastroenterologist . Common bile duct injuries-This topic will focus on the surgical repair of common bile duct injuries. Details of LC techniques and endoscopic management of complications from LC are discussed elsewhere
There was no free fluid ---in peritoneal cavity ;but pt had developed jaundice
Ercp and radiology imaging are nery helpful for management of bdi provided technical skill and expertise is availble…
Anniversary Award.-In 1990 in Atlanta, at the Society of American Gastrointestinal Surgeons (SAGES) Convention, Perissat, Berci, Cuschieri, Dubois, and Mouret were recognized by SAGES for performing early laparoscopic cholecystectomies, but Mühe was not. However, in 1999 he was recognized by SAGES for having performed the first laparoscopic cholecystectomy–sAGES invited Mühe to present the Storz Lecture. In Mühe's presentation, titled “The First Laparoscopic Cholecystectomy,” which he gave in March 1999 in San Antonio, Texas, he described the first procedure. Finally, Mühe had received the worldwide acclaim that he deserved for his pioneering work. One purpose of this article is to trace the development of the basic instruments used in laparoscopic cholecystectomy. The other purpose is to give Mühe the recognition he deserves for being the developer of the laparoscopic cholecystectomy procedur
Mühe followed each step of the surgical laparoscopy established by Semm; he first used lower abdominal access for the “Galloscope.” Later, Mühe introduced the laparoscope under the right costal arch. Fig. 12-7 in Highlights.
In 1972, Reynolds also began to use long pistol grip appliers and scissors to remove rectosigmoid polyps through a sigmoidoscope. After ligation of the polyp with hemoclips applied with a pistol grip applier, a cut was made between the hemoclips with the pistol grip scissors, and the polyp was removed. Reynolds' rectosigmoid polypectomy, developed in 1972, utilized these instruments for an open procedure that antedated their use in laparoscopic cholecystectomy. In rectosigmoid polypectomy, pistol grip appliers, scissors, and hemoclips are passed through tubes into the rectosigmoid colon for polypectomy. These maneuvers anticipated the essential techniques for laparoscopic cholecystectomy. 4 Reynolds began to perform minimally invasive open cholecystectomies using a pistol grip hemoclip applier and scissors to ligate and cut between the cystic duct and artery. 4 This procedure was accomplished by using a vertical, right upper rectus, muscle-sparing incision, retracting the rectus muscle medially. This type of cholecystectomy seemed to lessen postoperative pain as muscle fibers were not severed and allowed a quick recovery with a short postoperative hospitalization.
Laparoscopic cholecystectomy (LC) has replaced open surgery in the treatment of symptomatic cholecystolithiasis . Laparoscopy-offers advantages but complications such as (BDI) tend to be complex being more proximal and often associated with concomitant vascular injury + bowel injury raised the morbidity to 2.9% The spectrum of mishap has also changed due to the involvement of new instruments such as stapling device and energized instruments. Complications like migrating clips or spillage of gallstone into peritoneal cavity were completely unknown in open surgery. BDI- Recurrence of biliary stricture after a surgical repair can present many years later --
When this procedure was developed in 1989, surgeons rushed in massive numbers to learn the surgery, taking weekend courses in laparoscopic cholecystectomy by practicing on pigs and then rushing – lucratively – to patients.adding laparoscopic surgeon to their cvs-and sign boards…
Lap chole is a gold standard fr removal of diseased gb--Despite improvement in the technique and increasing experience, The transition from open to laparoscopic cholecystectomy – saw-- Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The transition from open to laparoscopic cholecystectomy incorporation and evaluation of new instrumentation, changing technology, and surgical technique. Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. Association:Increased mortality and morbidity;Reduced long-term survival;Reduced quality of life.;and among the leading sources of malpractice claims against surgeonsThe number of cholecystectomies performed laparoscopically has increased steadily since the introduction of this technique in the early 1990s .The consequences of these injuries can be catastrophic for the patient without appropriate management. Multiple articles published on this topic differ on ways to prevent, recognize and treat these types of injuries. Classifications of ductal injuries have been developed to adapt to the laparoscopic era
Laparoscopic cholecystectomy is the modern “gold . More recently it has been shown that the procedure can also be performed safely as a day-care procedure - Unfortunately, the data have demonstrated that the rate of BDI has not dropped below that of open cholecystectomy . In fact, studies indicate that the rate of BDI in laparoscopic surgery is approximately fivefold higher than that in open surgery [5,6]. Some have suggested that this complication rate has leveled off and is no longer improving [7].
It was a plausible and logical argument that the abrupt rise in bile duct injuries associated with the earliest efforts to perform laparoscopic cholecystectomy could be expected to drop significantly once surgeons and residents progressed beyond their own learning curve for this novel techniqu e. Although injury to the bile duct is rare during gb operations, an increase from 0.1% to about 0.6% -5% WERE been noted since the beginning of the laparoscopic era- LC—0.4 to 0.8% Traditional OC—0.1-0.3% Infrequent—but among the leading sources of malpractice claims against surgeons Despite improvement in the technique and increasing experience, Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. Association:Increased mortality and morbidity;Reduced long-term survival;Reduced quality of life . As of 2012, the percentage of injures to the bile duct during these procedures is 0.4%. . Additionally, multiple publications have quoted risk factors, such as lack of experience or overconfidence, as potentially precipitating injury.. With the advent of new procedures such as single-port and transluminal surgeries or natural orifice transluminal endoscopic surgery , the incidence of injury rising again is a real possibility. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. Awareness and preventative methods are of clinical importance to surgeons.- This presentation reviews the various causes and mechanisms –associated with bile duct injury
his year, more than 1 million people in the United States will learn they have gallstones. They will join the estimated 20 million Americans who have previously been diagnosed with this condition. Most people with gallstones are asymptomatic, typically remain symptom free for years, and require no treatment. However, each year more than 700,000 Americans develop symptomatic stones, requiring some form of intervention. While there are alternative nonsurgical forms of treatment, these remain palliative rather than curative.
Life is one great battlefield. This earth has been a field of battle through all the thousands of centuries of life here. And for many centuries to come it still must remain a field of battle. Those that survive must find their comfort in the heroism of the dead. And the race must find its lesson and its growth in the experiences and the suffering of the past .
To improve our results, we need to accurately identify the cause of our mistakes. Once points of risk are accurately identified, alternative instrumentation and techniques can be devised and evaluated to improve our outcomes. Objective To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. On a basic level, the fact that bile duct injuries associated with laparoscopic cholecystectomy tend to be more serious when they do occur should suggest that fundamental problems exist with this procedure. Have we been pushed into accepting and providing an operation for our patients that is less safe than the one it proposes to replace? After nearly 15 years of effort, can laparoscopic cholecystectomy be made safer?
Whether reasonable degree of medical probability ,standard of care;or there was departure from standard which resulted in physical I njury
Q for munir-Should we allow all nursing homes;hospitals to perform such operation?is there any had there to be bare minimium requirements before allowing them to operate2. ther has to be protocols basis for doing this surgery3.in case of BDI---what is the arrangemernt-is pt told about this complication?
Certification and accreditation???
Bungee jumping—a quick surgeon who thinks it is like a fastest man –in my time one of ther criteria of good surgeon was how fast he was??? A surgeon who does operation with minimum scar”,; another one answered, “a surgeon who operates without any complications”, one girl said, “operation with minimum bleeding”, etc…does surgery fast-----. The professor agreed with all those answers. But the most accurate answer he said was an old dictum, “ A good surgeon is one who knows when not to operate the patient”. Yes, it was a billion dollar answer told by our beloved sir . An untimely and unneeded operation can be a catastrophe. We have come across several patients getting worse after the surgery mandatory- Do NO More Harm While attending a surgery lecture in 3rd year BHMS, our surgery professor, Dr S D Bhomaj, FRCS, asked the students, “who is a good surgeon?” Immediately the Students gave different types of answers. Someone said---……. . It is true that tonsillectomy can remove tonsillitis forever. But the same patient may come with recurrent pharyngitis, which is more troublesome than the tonsillitis. On the other hand, it is an utter foolishness to give only medical treatment for purely surgical cases such as intestinal perforation, volvulus, rupture of viscera, compound fracture etc. In order to manage such cases, surgical management is
&quot;A good surgeon knows how to operate-A better surgeon knows when to operate-The best surgeon knows when not to operate&quot;
Indic of chole have not changed from open to lap—but why this sudden increase -- Include but are not limited to symptomatic cholelithiasis, thery Include but are not limited to symptomatic cholelithiasis, There is also a financial motivation that attracts surgeons to this minimally invasive procedure (including a lot of gallbladder removal procedures for patients that did not have stones
Is it happening—really in our practice---”dr munir can answer me—who us controlling this ---Summary and Conclusion; Despite wishful thinking, gall stones seldom disappear spontaneously. Statistics show that every year thousands of people have their gallbladders removed . Even today, only surgical removal of the gallbladder (laparoscopic/open cholecystectomy is treatment of choice) guarantees that the patient will not suffer a recurrence of gall stones. The advantages of surgical removal of the gallbladder over non-surgical treatment are the elimination of gallstones, and the prevention of gallbladder cancer. Issue of the development of carcinoma of the gall bladder in patients with long standing gall stones comes up frequently. Suffice it to say, the incidence of gall bladder cancer is infrequent enough that this argument in favor of prophylactic cholecystectomy is without merit. Patients with silent gall stones must be carefully evaluated in the context of their age, symptoms, and associated conditions in order to arrive at a decision for the optimal treatment of their calculous disease. In general, most patients with aysmtomatic calculi are best managed by continued observation- and not cholecystectomy.
Allah(SWT), the Almighty says in Noble Qur'an- The Bestower of Provision
One way to attempt to replicate the exposure provided by the open approach is using an angled telescope, which allows the cystic and common ducts to be viewed from the top down
The increased incidence of bile duct injury (BDI) after lap chole rates as high as 2% -5% reported in the early 'learning' phase ( first dozen cases ) and also after 50-100 Remarkably, other papers suggested that the majority of BDI was due to surgeons(REASONS) who were far beyond the learning curve , ##Learning curve is not only relevant for the occurrence of BDI, but that accidental injuries are partly due to failure of the technique. This learning curve contribution is now much less important, for surgical residents learn the procedure under direct supervision of more experienced surgeons.
Inflammation can cause the CHD to adhere to the gallbladder wall, making it appear that the surgeon has traced the cystic duct into the gallbladder rather than traced the CBD to the CHD. .The use of an infundibular view is an example of when intraoperative cholangiography may help avoid CHD injury in cases where the anatomy may seem clear.
tent the CBD out of normal location, leading to clip placement at the cystic duct-CBD junction. Cephalad traction on GB to tent the CBD out of normal location, leading to clip placement at the cystic duct-CBD junction. GB and CBD aligned by traction of GB
Overzealous use of electrocautery near Calot's triangle and extensive dissection around the CBD may damage its axial blood flow, leading to ischemic damage to the duct and late stricture formation
[1].sultan qaboos-;quick Infammation.nleeding;sacrring; stone imacted in hartmnas –c=short cysytic or mirrizis are local factors
HOW TO MINIMISE THE OCCURRENCE
Emphasis always is given to starting dissection high in the gallbladder neck in order to obtain the critical view , which decreases the chances of confusing normal anatomy. Avoid faulty technique -If you find yourself too close to the duodenum, you are probably not high enough and are most likely dissecting the common duct. In circumstances where inflammation brings the infundibulum into the hilar plate, obtaining this critical view may be challenging.
To this end, the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons
We do not currently recommend routine preoperative ERCP or perioperative cholangiography unless there is a high suspicion of common duct stones although the necessity of intraoperative cholangiography continues to be the subject of some controversy. Clinical indicators of risk for choledocholithiasis include initial liver function tests that are elevated, evidence of bile duct dilatation, persistent jaundice, evidence of pancreatitis, or active features of cholangiti In a prospective study of 303 patients undergoing LC, 148 had IOC performed routinely and 155 had selective IOC [ 13 ]. There was no significant difference in the mean operating time, retained common bile duct (CBD) stones or CBD injury. A prospective study of 1241 patients undergoing LC showed that routine IOC was feasible in 92 percent of cases and anatomic variations that influenced operative management were found in 13 percent of cases [ 14 ]. There were no complications from the IOC but there were four bile duct injuries despite the use of IOC.
Emphasis always is given to starting dissection high in the gallbladder neck in order to obtain the critical view , which decreases the chances of confusing normal anatomy. If you find yourself too close to the duodenum, you are probably not high enough and are most likely dissecting the common duct. In circumstances where inflammation brings the infundibulum into the hilar plate, obtaining this critical view may be challenging.
eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA A: Between October 2007 and September 2008, we studied the effects of the checklist in eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients. We prospectively collected data on clinical processes and outcomes from 3733 patients before and 3955 patients after the checklist was implemented. The results of the study were published in the New England Journal of Medicine on January 29, 2009 and demonstrated dramatic improvements in both processes and outcomes. Indeed, use of the checklist reduced the rate of deaths and complications by more than one third across all 8 pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8% after implementation of the checklist. Moreover, the effect was of similar magnitude in both high and low/middle income country sites, substantial improvements in outcomes, all at essentially no cost to the system.
Manouras et al. Journal of Medical Case Reports 2009 3 :44 doi:10.1186/1752-1947-3-44
To hav
Biliary fistullas--Ercp upper end cant be visualized –ptc lower end cant be visualisedp- mrcp will clealy dlineate both upper and lower ends
A recent report from the Amsterdam Medical center, however, has revived interest in this option. Between 1990 and 2006, 56 BDIs were managed with anastomosis (49 with a T tube) [26]. These were followed with a combination of endoscopic and radiological intervention as needed. The authors reported more than 90% stricture free rates during a mean followup of 7 years [26].
The goal of surgical repair of the injured biliary tract is the restoration of a durable conduit and the prevention of short- and long-term complications, ;The d iagnostic evaluation of the patient with biliary injuries should include accurate determination of the biliary anatomy. Suspected intra-abdominal abscess formation or vascular injury can be detected by computed tomography or magnetic resonance cholangiography. . The Johns Hopkins group had reported their results of repair of 142 BDIs performed between 1990 and 1999 with a mortality rate of 0.6%. At a mean followup of 55 months, excellent/good results were obtained in 91% of the patients. Thirteen patients had anastomotic failure and 10 of these were salvaged by reintervention [31]. In another study of 300 strictures performed between 1989 and 2006 the mortality rate was 1.3%. Among the 225 followed up for more than 2 years, 91% had excellent/good outcome whereas 11 patients required re-intervention for failure [37]. Two thirds of recurrence occurs within 2 years but stricture recurrence after 10 years have also been reported [38].
Mono polar cautery-The use of surgical clips-An advantageous 360-degree view-Anatomic variation-The indications for operative cholangiography-Misinterpretation of visual cues in the surgical field.Modifications to current techniques of laparoscopic cholecystectomy---accreditation-A willingness to consider equipment changes and alternative dissection method- The top down dissection
It is worth nothing: the NIH reports that laparoscopic gallbladder surgery injuries are more likely to occur when a surgeon has performed fewer than 25 procedures. This underscores the obvious: skill matters when a surgeon is removing a gallbladder. An error during gallbladder surgery ) is a common source of medical malpractice claims, largely because this is a common form of surgery. Most malpractice claims from gallbladder surgery occur when a surgeon does not know where the biliary ducts are on a patient and cuts where the surgeon should not be cutting. Can an experienced surgeon using ordinary care cut this common bile duct? The answer is almost certainly yes. But injury from cutting the common bile duct is often the result of medical malpractice. As any malpractice lawyer will tell you, it is the same surgeons who are “frequent flyers” in malpractice claims involving common bile duct injuries. Like an politician can tell you, what can often be the larger problem in a lap chole case is the what happens after the malpractice occurs. Sometimes, repair of an injury to the common bile duct during the procedure is a simple reconstruction of the duct. But the surgeon willfully ignores the injury or does not look to see if the common bile duct has been compromised, the injury might not be discovered until real damages has been done.
laparoscopic gallbladder surgery injuries are more likely to occur when a surgeon has performed fewer than 25 procedures. This underscores the obvious: skill matters when a surgeon is removing a gallbladder
More Harm than Every student in medical school takes the oath, “to first do no harm.” Yet, many doctors unwittingly do harm every day by blindly prescribing tests that have the potential to do more harm than good. While I wouldn’t tell you to avoid them altogether (sometimes they may be necessary), here are four medical tests I would ask a lot of questions about before agreeing to have them