Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Complications of laparoscopic cholecystectomy

Nezam H Afdhal, MD, FRCPI
Charles M Vollmer, Jr, MD
Section Editors
Stanley W Ashley, MD
Jeffrey Marks, MD
Deputy Editor
Wenliang Chen, MD, PhD


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 [1]. 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 [2,3]. 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 [4].

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'.)


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 [3,5-9]. 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 [10,11].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jan 19, 2017.
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 ©2017 UpToDate, Inc.
  1. Management of Benign Biliary Stenosis and Injury: A Comprehensive Guide, Dixon E, Vollmer CM Jr, May GR (Eds), Springer International Publishing, Switzerland 2015.
  2. Vollmer CM Jr, Callery MP. Biliary injury following laparoscopic cholecystectomy: why still a problem? Gastroenterology 2007; 133:1039.
  3. 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.
  4. Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the laparoendoscopic era. Am J Surg 2008; 195:108.
  5. Catarci M, Zaraca F, Scaccia M, Carboni M. Lost intraperitoneal stones after laparoscopic cholecystectomy: harmless sequela or reason for reoperation? Surg Laparosc Endosc 1993; 3:318.
  6. Cervantes J, Rojas GA, Ponte R. Intrahepatic subcapsular biloma. A rare complication of laparoscopic cholecystectomy. Surg Endosc 1994; 8:208.
  7. Stupak D, Cohen S, Kasmin F, et al. Intra-abdominal actinomycosis 11 years after spilled gallstones at the time of laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2007; 17:542.
  8. Roberts DJ, Chun HM. Dropped gallstone as a nidus of intra-abdominal abscess complicated by empyema. Clin Infect Dis 2005; 41:e64.
  9. Binenbaum SJ, Goldfarb MA. Inadvertent enterotomy in minimally invasive abdominal surgery. JSLS 2006; 10:336.
  10. Strasberg SM. Biliary injury in laparoscopic surgery: part 1. Processes used in determination of standard of care in misidentification injuries. J Am Coll Surg 2005; 201:598.
  11. Strasberg SM. Biliary injury in laparoscopic surgery: part 2. Changing the culture of cholecystectomy. J Am Coll Surg 2005; 201:604.
  12. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180:101.
  13. Thurley PD, Dhingsa R. Laparoscopic cholecystectomy: postoperative imaging. AJR Am J Roentgenol 2008; 191:794.
  14. Biscione FM, Couto RC, Pedrosa TM, Neto MC. Comparison of the risk of surgical site infection after laparoscopic cholecystectomy and open cholecystectomy. Infect Control Hosp Epidemiol 2007; 28:1103.
  15. Moore MJ, Bennett CL. The learning curve for laparoscopic cholecystectomy. The Southern Surgeons Club. Am J Surg 1995; 170:55.
  16. Morgenstern L, McGrath MF, Carroll BJ, et al. Continuing hazards of the learning curve in laparoscopic cholecystectomy. Am Surg 1995; 61:914.
  17. Richardson MC, Bell G, Fullarton GM. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 1996; 83:1356.
  18. Z'graggen K, Wehrli H, Metzger A, et al. Complications of laparoscopic cholecystectomy in Switzerland. A prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery. Surg Endosc 1998; 12:1303.
  19. Hobbs MS, Mai Q, Knuiman MW, et al. Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy. Br J Surg 2006; 93:844.
  20. 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.
  21. Nuzzo G, Giuliante F, Giovannini I, et al. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 2005; 140:986.
  22. Joseph M, Phillips MR, Farrell TM, Rupp CC. Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution. Ann Surg 2012; 256:1.
  23. Fundamentals of laparoscopic surgery. www.flsprogram.org (Accessed on December 08, 2008).
  24. Swanstrom LL, Fried GM, Hoffman KI, Soper NJ. Beta test results of a new system assessing competence in laparoscopic surgery. J Am Coll Surg 2006; 202:62.
  25. Davidoff AM, Branum GD, Meyers WC. Clinical features and mechanisms of major laparoscopic biliary injury. Semin Ultrasound CT MR 1993; 14:338.
  26. 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.
  27. Woods MS, Traverso LW, Kozarek RA, et al. Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography. Surg Endosc 1995; 9:1076.
  28. Ladocsi LT, Benitez LD, Filippone DR, Nance FC. Intraoperative cholangiography in laparoscopic cholecystectomy: a review of 734 consecutive cases. Am Surg 1997; 63:150.
  29. Lillemoe KD. Current management of bile duct injury. Br J Surg 2008; 95:403.
  30. Woods MS, Shellito JL, Santoscoy GS, et al. Cystic duct leaks in laparoscopic cholecystectomy. Am J Surg 1994; 168:560.
  31. Nuñez D Jr, Becerra JL, Martin LC. Subhepatic collections complicating laparoscopic cholecystectomy: percutaneous management. Abdom Imaging 1994; 19:248.
  32. Boland GW, Mueller PR, Lee MJ. Laparoscopic cholecystectomy with bile duct injury: percutaneous management of biliary stricture and associated complications. AJR Am J Roentgenol 1996; 166:603.
  33. Brugge WR, Alavi A. Cholescintigraphy in the diagnosis of the complications of laparoscopic cholecystectomy. Semin Ultrasound CT MR 1993; 14:368.
  34. Dixon E, Sutherland FR, Vollmer CM Jr, Greig PD. Bile duct injury after laparoscopic cholecystectomy: resection of the entire extrahepatic biliary tree. J Am Coll Surg 2003; 197:862.
  35. Khalid TR, Casillas VJ, Montalvo BM, et al. Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury. AJR Am J Roentgenol 2001; 177:1347.
  36. Vitellas KM, El-Dieb A, Vaswani K, et al. Detection of bile duct leaks using MR cholangiography with mangfodipir trisodium (Teslascan). J Comput Assist Tomogr 2001; 25:102.
  37. Pencev D, Brady PG, Pinkas H, Boulay J. The role of ERCP in patients after laparoscopic cholecystectomy. Am J Gastroenterol 1994; 89:1523.
  38. Schmitt CM, Baillie J, Cotton PB. ERCP following laparoscopic cholecystectomy: a safe and effective way to manage CBD stones and complications. HPB Surg 1995; 8:187.
  39. Vitale GC, Stephens G, Wieman TJ, Larson GM. Use of endoscopic retrograde cholangiopancreatography in the management of biliary complications after laparoscopic cholecystectomy. Surgery 1993; 114:806.
  40. Shimada H, Endo I, Shimada K, et al. The current diagnosis and treatment of benign biliary stricture. Surg Today 2012; 42:1143.
  41. Strasberg SM, Callery MP, Soper NJ. Laparoscopic hepatobiliary surgery. Prog Liver Dis 1995; 13:349.
  42. Ball CG, MacLean AR, Kirkpatrick AW, et al. Hepatic vein injury during laparoscopic cholecystectomy: the unappreciated proximity of the middle hepatic vein to the gallbladder bed. J Gastrointest Surg 2006; 10:1151.
  43. Bishoff JT, Allaf ME, Kirkels W, et al. Laparoscopic bowel injury: incidence and clinical presentation. J Urol 1999; 161:887.
  44. Landman MP, Feurer ID, Moore DE, et al. The long-term effect of bile duct injuries on health-related quality of life: a meta-analysis. HPB (Oxford) 2013; 15:252.
  45. Alkhaffaf B, Decadt B. 15 years of litigation following laparoscopic cholecystectomy in England. Ann Surg 2010; 251:682.
  46. Melton GB, Lillemoe KD, Cameron JL, et al. Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg 2002; 235:888.
  47. Callery MP. Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations. Surg Endosc 2006; 20:1654.
  48. Buddingh KT, Nieuwenhuijs VB, van Buuren L, et al. Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 2011; 25:2449.
  49. Sanford DE, Strasberg SM. A simple effective method for generation of a permanent record of the Critical View of Safety during laparoscopic cholecystectomy by intraoperative "doublet" photography. J Am Coll Surg 2014; 218:170.
  50. Booij KA, de Reuver PR, Nijsse B, et al. Insufficient safety measures reported in operation notes of complicated laparoscopic cholecystectomies. Surgery 2014; 155:384.
  51. Avgerinos C, Kelgiorgi D, Touloumis Z, et al. One thousand laparoscopic cholecystectomies in a single surgical unit using the "critical view of safety" technique. J Gastrointest Surg 2009; 13:498.