Complications of laparoscopic cholecystectomy
- Nezam H Afdhal, MD, FRCPI
Nezam H Afdhal, MD, FRCPI
- Chief of Hepatology
- Beth Israel Deaconess Medical Center
- Charles M Vollmer, Jr, MD
Charles M Vollmer, Jr, MD
- Professor of Surgery
- University of Pennsylvania School of Medicine
In the late 1980s after the first successful laparoscopic cholecystectomy in Europe, this revolutionary minimally invasive surgery rapidly became the accepted technique for the treatment of gallbladder disease in the United States. The rapid acceptance of this new technique by the medical profession and the public was related to the obvious advantages of reduced cost, decreased hospital length of stay, and increased patient satisfaction.
Few clinical studies were performed to compare this new procedure to standard open cholecystectomy. As laparoscopic cholecystectomy gained wider acceptance, complications which were rarely seen with open cholecystectomy, such as bile duct injury, were reported in as many as 5 percent of patients. At present, approximately 750,000 laparoscopic cholecystectomies are performed annually in the United States (accounting for roughly 90 percent of all cholecystectomies) with an overall serious complication rate that remains higher than that seen in open cholecystectomy, despite increasing experience with the procedure [1,2]. The complication rate of open cholecystectomy has increased as well, due to overall declining experience in open surgery as this approach is now reserved for the most complicated and challenging cases .
This topic review will discuss complications that are specifically related to or more commonly encountered with the laparoscopic procedure. The management of acute cholecystitis, indications and surgical techniques for laparoscopic cholecystectomy, common bile duct exploration, and repair of common bile duct injuries are discussed elsewhere in detail. (See "Treatment of acute calculous cholecystitis" and "Laparoscopic cholecystectomy" and "Endoscopic management of complications from laparoscopic cholecystectomy" and "Common bile duct exploration" and "Repair of common bile duct injuries".)
Other adverse outcomes, such as retained common bile duct stones (incidence of around 10 percent), postcholecystectomy syndromes, and misdiagnoses (sphincter of Oddi dysfunction) occur with the same frequency with both laparoscopic and open cholecystectomy and will not be discussed here. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Clinical manifestations and diagnosis of sphincter of Oddi dysfunction" and "Laparoscopic cholecystectomy", section on 'Postcholecystectomy syndrome'.)
COMPLICATIONS OF LAPAROSCOPIC APPROACH
Serious complications that occur with laparoscopic cholecystectomy, including bile duct injury, bile leaks, bleeding and bowel injury result in part from patient selection, surgical inexperience, and the technical constraints that are inherent to the minimally invasive approach [2,4-8]. A major mode of ductal injury is diathermy burns, which may initially go unnoticed and usually involve the right or common hepatic ducts. These factors, as well as intrinsic sequelae of biliary tract diseases, such as inflammation and scarring, have led to the concept of "Stop Rules" for surgeons performing this operation. In essence, if a safe dissection cannot be ensured laparoscopically, early conversion to an open approach should be readily accepted as the proper course [9,10].
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- COMPLICATIONS OF LAPAROSCOPIC APPROACH
- Surgeon experience
- Patient selection
- BILIARY INJURY CLASSIFICATION
- Type A
- Type B and C
- Type D
- Type E
- DIAGNOSIS AND MANAGEMENT OF BILIARY INJURIES
- Biliary and cystic duct leaks
- - Type A
- - Types C and D
- - Radiologic workup
- - Management after diagnosis
- Occlusive injury to the right hepatic duct (Type B injury)
- Injuries to common bile or common hepatic ducts (Type E injury)
- BLEEDING COMPLICATIONS
- BOWEL INJURY
- POSTCHOLECYSTECTOMY SYNDROME
- QUALITY OF LIFE AFTER BILE DUCT INJURY
- INJURY PREVENTION
- SUMMARY AND RECOMMENDATIONS