Avoiding Complication Laparoscpy 2014 English

Avoiding Complications in Laparoscopic Cholecystectomy

Daniel Ludi MD
Objectives
Understanding the magnitude of the problem Cause and prevention of misidentification injuries What to do if you have an injury in the operating room What to do with an injury post op How to protect your self in case of a litigation
LHD
RHA
RHD
I never had a complication !!
It is important to learn from our mistakes But it is even better to learn from somebody elses mistakes
Incidence of Lap Chole Injury

LC carries a nearly two fold higher risk of major bile, vascular, and bowel complications (Australia) Concomitant intestinal injury 15% (Mexico)
Fletcher Dr. Ann Surg, 1999:229;449-457 Mercado MA, Curr Surg 2004:61:380-385
US Incidence: 1989-1995 Probably under reported

Publication bias Voluntary reporting via publication
If National Registries are more accurate of true incidence of CBDI, then risk is 10x over open chole
Between 34% and 49% of surgeons are expected to cause such an injury during their career
Archer SB, BrownDW, Smith CD, et al. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001;234:549558; discussion 558559
Francoeur JR, Wiseman K, Buczkowski AK, et al. Surgeons anonymous response after bile duct injury during cholecystectomy. Am J Surg 2003;185:468475
Surgical Experience
Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001; 234: 549559.
Surgical Experience
One third of surgeons reporting an injury in either group reported that the injury occurred after having completed 200 cases
Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg 2001; 234: 549559.
Bile duct injury should be regarded as preventable, but over 70 % of surgeons regard it as unavoidable
Francoeur JR, Wiseman K, Buczkowski AK, Chung SW, Scudamore CH. Surgeons anonymous response after bile duct injury during cholecystectomy. Am J Surg 2003; 185: 468475.
Why Have CBD Injuries Increased?

Inexperience with laparoscopic techniques and equipment & inadequate training Inappropriate dissection methods Inadequate plan for conclusively identifying the cystic duct and bile ducts Resistance to performing IOC

Hesitancy to convert to open chole Lack of familiarity with top down technique or partial cholecystectomy Lack of understanding of anatomy and mechanisms of injury

Poor visualization
Use of zero degree scope Inadequate use of hemostatic devices
Visual misperception mirage

Human Error, cognitive psychology CBD misidentified as cystic duct
Strasberg S, J Am Coll Surg, 2000, 191:661-667 Way L, Ann Surg 2003, 237:460-469
Arterial anomalies
Two cystic arteries Posterior cystic artery Lateral cystic artery Superficial Rt. hepatic artery
Avoiding Complications in Laparoscopic Anatoma Arterial Cholecystectomy
Avoiding Complications in Laparoscopic Anatoma Arterial Cholecystectomy
Opening the Posterior Peritoneum
Dissection plane
North American Approach

Dissection begins high on the gallbladder Lateral to cystic artery Hug GB wall, extend Peritoneal incisions Anterior and posterior To the liver edge
Isolating The Cystic Artery
Strasbeg Sm. Herti M Soper NJ An analysis of the problem of biliry Injury during laparoscopic cholecystectomy J Am Coll surg 180:101-25, 1995
The Critical View of Safety
Safe Cystic Duct Ligation

Clips: see tips, extended beyond width of duct Wide or short duct
Endoloop Hand tied ligation Suture closure
Gallbladder neck closure

Endoloop Running suture Stapler
If insecure or unsure place drain
Predictors of Difficult Cholecystectomy

Urgent Cholecystectomy for Acute Cholecystitis
The presence of AC is a risk factor for conversion = operative difficulty Strongest predictors of difficulty
Timing of surgery > 48hrs after the onset of symptoms Leukocytosis>18K Others predictors
Palpable GB, Maleness, Age
Elective LC
Major risk factor is thick GB wallespecially thick and contracted GB Other: Prior acute cholecystitis, multiple attacks of pain, maleness, age, obesity, previous surgery Conversion rates are much lower 3-5% Look for combination of variables
Oteher Possible Concomitant Problems

Cholangitis Acute Pancreatitis especially in acute cholecystitis Liver disease/Cirrhosis/Portal Hypertension
Rationale for Ductal Identification

1. Infundibular Technique 2. Identify Cystic Duct/Common Bile Duct Junction 3. Critical View Technique 4. Cholangiography
Factors associated with failure of the infundibular technique

Acute Inflamation
Thick GB wall GB distension Impacted stone
Severe Chronic Inflamation

Thick GB wall Impacted stone
Intrahepatic GB Adhesions
Rationale for Ductal Identification

1. Infundibular Technique 2. Identify Cystic Duct/Common Bile Duct Junction 3. Critical View Technique 4. Cholangiography
When the critical view cannot be achieved

Early IOC through GB Top Down (French) Approach Partial cholecystectomy Convert to open Cholecystostomy tube
Operative Cholangiography
Operative cholangiography significantly reduced the risk of injury even after adjustment for age, gender, hospital type and, severity of disease
Fletcher DR et al. Ann Surg 229:449, 1999
Reasons Why Routine IOC Does Not Make a Difference

Bad technique or misinterpreted
80% read as nl when injury was present
Performed after clipping/cutting Dont indentify thermal injury at time of op Injury can occur later with false interpretation and illusion Tenting injury by clipping CBD
Carroll BJ, Surg Endosc, 1996:10:1194-1197
Argument for Routine Intra Operative Cholangiography

Identifies injury intra-operatively when interpreted correctly Reduce severity, morbidity, late sequelai and costs 11/12 injuries identified in 3,242 LCs
All injuries Bismuth I,II 10 were primary repairs, 1 hepaticojejunostomy
Carroll BJ, Surg Endosc, 1996:10:1194-1197
Risk Reduction with Routine IOC

Fletcher, Australia
50% reduction in 7,000 LCs
Flumm, Washington State 1991-97

67% reduction in 30,000 LCs
Flumm D, Ach Surg, 2001:136:1287-1292 Fletcher Dr. Ann Surg 1999:229:449-457
Intra-Opertive Cholangiography
Medicare Pts, 112-99 1,570,361 cholecystectomies 7911 CBD injuries (0.5%)
With IOC (0.39%) Without IOD (0.58%)
When the critical view cannot be achieved

Early IOC through GB Top Down (French) Approach Partial cholecystectomy Convert to open Cholecystostomy tube
Cirrhosis, Portal Hypertension and Cholecystectomy

Does the patient need the operation? Childs A only Lower portal pressure with drugs and have veno-veno bypass available The surgeon doing the operation should be experienced in operating on patients with portal hypertension and in doing cholecystectomy
Completing a Difficult Cholecystectomy without Completing the Cholecystectomy

Cholecystostomy Patial cholecystectomy
With a tube Leave back wall of GB in and close cystic duct from inside. Ablating GB mucosa is an option.
Avoiding Complications Error trap 2 in Laparoscopic Cholecystectomy
Top Down, Partial Chole
Partial Lap Chole: Cirrhosis, Portal HTN
This is safer than North American Technique And can be sused in all patients
Endo Looping the Neck
Double Ligated Neck
Should I convert to an open procedure?

To stop bleeding? Yes
To do the repair?
Yes if within my skill set
To diagnose injury? Only if repair injury To drain only? No
Tipos de Lesiones
46 casos 15 transecciones 11 excisiones 6 laceraciones 8 lesiones por mala colocacin de los clips 3 lesiones con electrocauterio 2 fuga biliar del lecho hepatico y ductos aberrantes 1 fuga biliar a traves del cistico
B. J. Carroll Common bile duct injuries during laparoscopic cholecystectomy that result in litigation Surg Endosc (1998) 12: 310314
Common Scenarios In CBDI

80% not recognized at surgery Cholangiograms misinterpreted 70% Delay in Dx >5 days Low success when repaired by primary surgeon (25%) vs. experienced (80%)
End to end fail in majority of pts
Carroll BJ, Surg Endosc 1998: 12:310-314
Intraoperative Detection of CBDI

Convert to open, perform IOC
When present-do correct repair of refer Avoid primary end to end
RY hepaticojejunostomy for transection High anastomosis
Mercado MA, Surg Endosc 2003, 17:1351-1355
Can things be made worse?

The best chance for a lasting repair is the FIRST repair. Specialist HPB surgeons( individuals commonly doing bile duct and liver resections) get better result in difficult repairs (high injuries, small ducts, multiples ducts, associated vascular injuries)
Can things be made worse?

Primary Surgeons successful outcome 27% Referral Surgeons successful outcome 79%
Carroll BJ, Surg Endosc 1998: 12:310-314
Early Referral to a tertirary care center with experienced hepatobiliary Surgeons would appear to be necessary to assure optimal results
Surgical Management of Bile Duct Injuries Sustained During Laparoscopic Cholecystectomy Perioperative Results in 200 Patients Jason K. Sicklick, MD(Ann Surg 2005;241: 786795)
Surgeons who specialize in the repair of bile duct injuries achieve much better results than those with less experience
Bile Duct Injuries During Laparoscopic CholecystectomyFactors That Influence the Results of Treatment Lygia Stewart, MD; Lawrence W. Way, MD Arch Surg. 1995;130(10):1123-1128.
Timing of Repair
Immediate is preferred Hence, intrao recognition is importat
Increased chance of injury site control and avoidance of bile peritonitis, obstructive jaundice Reduce mortality, costs, LOS
Diagnosing and Staging of Reapir

Influenced by type and time of recognition Intraop suspicion Immediate post op Intermediate post op (>2-5days) Delayed (> 10 days
Chapman WC, J Gastrointest Surg. 2003, 7:412-416
Intraoperative Detection of CBDI

Decision to refer to lack of experience Obtain control of bile leak
Intubate bile duct, externally divert Drain with close susction drains
Call receiving surgeon Immediate transfer
Immediate Post Op Detection

Establish DX
Ralapasroscope < 24 hr ERCP, HIDA
Decide if reoperation indicated vs non operative management
Most injuries identified < 72 hr can undergo safe immediate definitive repair Defer repair if septic or unstable
More Delayed Injury (> 5 days)

Assure adequate surgical site control
Biliary diversion External draingage Treat sepsis
Delayed repair at 3-5 months Major duct loss of tangential injuries usually fail non operative treatment
Treatment for Isolated Right Duct: Strasberg Class C

Usually poorly dx by GI, ERCP Requires experienced eye, demonstration of all ducts by cholangiography If clean and < 2 mm: ligate If contaminated and/or > 3mm: consider RY hepaticojejunostomy
Isolated Segment VI
Isolated Segment VII: Previously into Cystic Duct
VII
Will carefull dissection alone solve the problem of biliary injury? Or Do we need to change the CULTURE OF CHOLECYSTECTOMY
Changing the Culture of Cholecystectomy Choletithiasis is a benign disease A cholecystectomy never HAS TO BE done in the face of severe inflammation The benefit of completing a cholecystectomy is a minor compared to the benefit of avoiding a biliary injury
Changing the Culture of Cholecystectomy We must teach not only how to avoid injury but to avoid entering the zone of great danger in which an injury can occur.
This applies doubly when conversion occurs and the problem becomes a difficult OPEN cholecystectomy
Oops! Just cut The Bile Duct! What do I Do Now? Medico-Legal Aspect
15 % of all indemnity in general surgery is from biliary injuries

Preparedness Be Prepared to Answer These Question Before Starting a Cholecystectomy
How to dictate the operative note when and injury has occurred How to refer the patient How to discuss the injury with the patient and the family
Operative Note
Dictate the note on the day of surgery when memories are clearest. Before beginning = jot down a list of the point to be made Describe the operative conditions clearly, completely but without exaggeration Include the rationale for cystic duct and artery identification clearly Describe consultations
How to refer the patient

Call and speak to the accepting surgeon Use HOLINES or Doctors Access Lines if necessary
How to discuss the injury with the patient and the family
Present what is known about the injury, its intended investigation and treatment in clear lay terms (and pictures). Dont tell what you dont know or are not sure and dont make judgmental statements If referral is to be made tell patient that this contact has been made personally, and provide the name and area of interest of the accepting surgeon to the patient.
Litigation
50% are litigated Avg settlement: $ 1 million 80% settle in favor of plaintiff Difficult to defend for many reasons
Factores Leading to Litigation

Complications resulting from delay in Dx Treatment failures for immediately recognized injuries Failure to provide adequate safety net for pt in post operative period
Unavailability, inadequate cross coverage
Carroll BJ. Surg Edosc 1998: 12:310-314
Results Following Repair of CBDI

85-95% initial success Higher failure rate with concomitant vascular injury Long term success: 80% when repair by experienced surgeon vr 25%
Avoiding Injury of the CBD

Dissect a triangle and NOT a duct Be more liberal with IOC When the anatomy is not clear convert When bleeding present do not cauterize or apply clips blindly Something is wrong if you need more than 8 clips
Summary
CBDI are infrequent Most are preventable Early recognition results in best outcomes High repair is preferable for type E If you lack experience with these repairs, refer patient early

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Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

I never had a complication !!

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Incidence of Lap Chole Injury

Avoiding Complications in Laparoscopic Cholecystectomy

US Incidence: 1989-1995 Probably under reported

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Why Have CBD Injuries Increased?

Avoiding Complications in Laparoscopic Cholecystectomy

Why Have CBD Injuries Increased?

Avoiding Complications in Laparoscopic Cholecystectomy

Why Have CBD Injuries Increased?

Visual misperception mirage

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Anatoma Arterial Cholecystectomy

Avoiding Complications in Laparoscopic Anatoma Arterial Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Opening the Posterior Peritoneum

Avoiding Complications in Laparoscopic Cholecystectomy

North American Approach

Avoiding Complications in Laparoscopic Cholecystectomy

Isolating The Cystic Artery

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

The Critical View of Safety

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Safe Cystic Duct Ligation

Gallbladder neck closure

If insecure or unsure place drain

Avoiding Complications in Laparoscopic Cholecystectomy

Predictors of Difficult Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Oteher Possible Concomitant Problems

Avoiding Complications in Laparoscopic Cholecystectomy

Rationale for Ductal Identification

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in Laparoscopic Cholecystectomy