Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Endoscopic management of complications from laparoscopic cholecystectomy

Michael K Sanders, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF


Iatrogenic injury to the biliary tree is a well-documented complication of cholecystectomy. This topic review will focus on the role of the endoscopist in the management of these disorders. It is important to appreciate that several injuries, particularly complex hilar lesions or total transections, are usually not amenable to endoscopic treatment. An overview of the complication of laparoscopic cholecystectomy is provided separately. (See "Complications of laparoscopic cholecystectomy".)


The introduction of laparoscopic cholecystectomy and its sudden and widespread implementation in the early 1990s led to a dramatic increase in the frequency of biliary injury. With increasing experience, the incidence of this complication has declined substantially (from 2.2 percent in a report from 1991 to an overall incidence of 0.6 percent from several more recent series) [1-3].

However, the incidence has probably reached a plateau. This was illustrated in a report from a high-volume tertiary referral center, in which the frequency and distribution of bile duct injuries detected by ERCP over a nine-year period (from 1994 to 2003) remained unchanged [4]. The actual incidence of biliary injuries may be higher than the above estimates since not all series classified bile leaks that did not require operative management as a complication.

Successful management of bile duct injury requires a multidisciplinary team approach incorporating experienced biliary endoscopists, interventional radiologists, and hepatobiliary surgeons. The approach to the patient depends upon the nature and extent of the injury, the presence or absence of biloma, and the timing of discovery. Debate continues within the surgical literature as to whether routine intraoperative cholangiography reduces the risk of biliary complications [5,6].

A general classification of biliary injuries has been proposed although it is not universally accepted (figure 1) [7]. (See "Complications of laparoscopic cholecystectomy".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Nov 11, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991; 324:1073.
  2. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 1993; 165:9.
  3. McMahon AJ, Fullarton G, Baxter JN, O'Dwyer PJ. Bile duct injury and bile leakage in laparoscopic cholecystectomy. Br J Surg 1995; 82:307.
  4. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007; 65:247.
  5. Kullman E, Borch K, Lindström E, et al. Value of routine intraoperative cholangiography in detecting aberrant bile ducts and bile duct injuries during laparoscopic cholecystectomy. Br J Surg 1996; 83:171.
  6. Wright KD, Wellwood JM. Bile duct injury during laparoscopic cholecystectomy without operative cholangiography. Br J Surg 1998; 85:191.
  7. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180:101.
  8. Kitami M, Murakami G, Suzuki D, et al. Heterogeneity of subvesical ducts or the ducts of Luschka: a study using drip-infusion cholangiography-computed tomography in patients and cadaver specimens. World J Surg 2005; 29:217.
  9. Ko K, Kamiya J, Nagino M, et al. A study of the subvesical bile duct (duct of Luschka) in resected liver specimens. World J Surg 2006; 30:1316.
  10. Elboim CM, Goldman L, Hann L, et al. Significance of post-cholecystectomy subhepatic fluid collections. Ann Surg 1983; 198:137.
  11. Trondsen E, Ruud TE, Nilsen BH, et al. Complications during the introduction of laparoscopic cholecystectomy in Norway. A prospective multicentre study in seven hospitals. Eur J Surg 1994; 160:145.
  12. Barkun AN, Rezieg M, Mehta SN, et al. Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc 1997; 45:277.
  13. Bergman JJ, van den Brink GR, Rauws EA, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996; 38:141.
  14. Davidoff AM, Branum GD, Meyers WC. Clinical features and mechanisms of major laparoscopic biliary injury. Semin Ultrasound CT MR 1993; 14:338.
  15. Aduna M, Larena JA, Martín D, et al. Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdom Imaging 2005; 30:480.
  16. Bourke MJ, Elfant AB, Alhalel R, et al. Endoscopic management of postoperative bile leak in 85 patients. Gastrointest Endosc 1995; 41:390.
  17. Liguory C, Vitale GC, Lefebre JF, et al. Endoscopic treatment of postoperative biliary fistulae. Surgery 1991; 110:779.
  18. Davids PH, Rauws EA, Tytgat GN, Huibregtse K. Postoperative bile leakage: endoscopic management. Gut 1992; 33:1118.
  19. Ryan ME, Geenen JE, Lehman GA, et al. Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review. Gastrointest Endosc 1998; 47:261.
  20. Hourigan LF, Bourke MJ, Williams SJ. Endoscopic management of postoperative bile leak in 53 patients (abstract). J Gastroenterol Hepatol 1999; 14:A145.
  21. Kaffes AJ, Hourigan L, De Luca N, et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005; 61:269.
  22. Sandha GS, Bourke MJ, Haber GB, Kortan PP. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004; 60:567.
  23. Chow S, Bosco JJ, Heiss FW, et al. Successful treatment of post-cholecystectomy bile leaks using nasobiliary tube drainage and sphincterotomy. Am J Gastroenterol 1997; 92:1839.
  24. Kahaleh M, Sundaram V, Condron SL, et al. Temporary placement of covered self-expandable metallic stents in patients with biliary leak: midterm evaluation of a pilot study. Gastrointest Endosc 2007; 66:52.
  25. Seewald S, Groth S, Sriram PV, et al. Endoscopic treatment of biliary leakage with n-butyl-2 cyanoacrylate. Gastrointest Endosc 2002; 56:916.
  26. Shami VM, Talreja JP, Mahajan A, et al. EUS-guided drainage of bilomas: a new alternative? Gastrointest Endosc 2008; 67:136.
  27. Coelho-Prabhu N, Baron TH. Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak. Am J Gastroenterol 2010; 105:100.
  28. Davids PH, Tanka AK, Rauws EA, et al. Benign biliary strictures. Surgery or endoscopy? Ann Surg 1993; 217:237.
  29. Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 2000; 232:430.
  30. Schol FP, Go PM, Gouma DJ. Outcome of 49 repairs of bile duct injuries after laparoscopic cholecystectomy. World J Surg 1995; 19:753.
  31. Woods MS, Traverso LW, Kozarek RA, et al. Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study. Am J Surg 1994; 167:27.
  32. Bourke MJ, Elfant AB, Alhalel R, et al. Sphincterotomy-associated biliary strictures: features and endoscopic management. Gastrointest Endosc 2000; 52:494.
  33. Baron TH, Feitoza AB, Nagorney DM. Successful endoscopic treatment of a complete transection of the bile duct complicating laparoscopic cholecystectomy. Gastrointest Endosc 2003; 57:765.
  34. Dumonceau JM, Baize M, Devière J. Endoscopic transhepatic repair of the common hepatic duct after excision during cholecystectomy. Gastrointest Endosc 2000; 52:540.
  35. Berkelhammer C, Kortan P, Haber GB. Endoscopic biliary prostheses as treatment for benign postoperative bile duct strictures. Gastrointest Endosc 1989; 35:95.
  36. Davids PH, Rauws EA, Coene PP, et al. Endoscopic stenting for post-operative biliary strictures. Gastrointest Endosc 1992; 38:12.
  37. Geenen DJ, Geenen JE, Hogan WJ, et al. Endoscopic therapy for benign bile duct strictures. Gastrointest Endosc 1989; 35:367.
  38. Duvall A, Haber GB, Kortan P, et al. Long term follow up of endoscopic stenting for benign postoperative bile duct strictures (abstract). Gastrointest Endosc 1997; 45:AB129.
  39. Costamagna G, Pandolfi M, Mutignani M, et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001; 54:162.
  40. Bergman JJ, Burgemeister L, Bruno MJ, et al. Long-term follow-up after biliary stent placement for postoperative bile duct stenosis. Gastrointest Endosc 2001; 54:154.
  41. Costamagna G, Tringali A, Mutignani M, et al. Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc 2010; 72:551.
  42. Lee JG, Leung JW. Long-term follow-up after biliary stent placement for postoperative bile duct stenosis. Gastrointest Endosc 2001; 54:272.