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British Journal of Surgery 1995, 82, 307-313 Review Bile duct injury and bile leakage in laparoscopic cholecystectomy A . J . M c M A H O N , G . F U L L A R T O N * , J . N . B A X T E R T and P . J . O ' D W Y E R University Departments of Surgery, Western Infirmary, ?Royal Infirmary, and *Department of Surgery, Gartnavel General Hospital, Glasgow, UK Correspondence to: Mr A . McMahon, Department of Surgery, Western General Hospital, Edinburgh EH4 2XU, UK The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general. Until the end of the 1980s open cholecystectomy remained the treatment of choice for symptomatic cholelithiasis because of its efficacy and excellent safety record. In the past 5 years, laparoscopic cholecystectomy has replaced open cholecystectomy as the 'gold standard' treatment because of the reduction in postoperative pain and pulmonary dysfunction, shorter hospital stay and more rapid return to normal activity'. However, introduction of the technique has been marred by reports of a higher incidence of major complications and, in particular, bile duct injury2, which is a catastrophic event that can lead to significant long-term morbidity (recurrent stricture, cholangitis, cirrhosis and premature death)3. This review sets out to compare the incidence of bile duct injury after open and laparoscopic cholecystectomy, and to establish whether the increased incidence is a problem inherent in the newer technique, a result of the learning curve phenomenon, or related to better reporting. It is difficult to calculate accurately the incidence of bile duct injury after open or laparoscopic cholecystectomy for four reasons: first, it is an uncommon problem; second, bile duct injury may present months after surgery; third, voluntary audit probably results in under-reporting; and fourth, there are variations in the definition of what constitutes bile duct injury. Reports from specialized centres are unlikely to represent what occurs in everyday practice. Even surveys across the whole community, such as that carried out by Deziel et aL4 in which surgeons were asked to volunteer data retrospectively on biliary complications, probably underestimate the true incidence. Table 1 Bile duct injury rate in reported series of open cholecystectomy Incidence of bile duct injury after open cholecystectomy Table I shows that the incidence of bile duct injury in reported of open cholecystectomy ranges from 0 to 0.5 per cent. Thus, on average, one bile duct injury occurs in every 200-300 cases of open cholecystectomy. The series reported by Roslyn et ~ 1 . was ' ~ a retrospective audit using information from computerized discharge data from all hospitals in California and Maryland in 1989. The 91 patients (0.2 per cent) in this series with possible bile duct injury included patients with laceration of the Paper accepted 25 October 1994 No. of patients Reference Period Vanderpool et aL5 Ganey et al.' Warwick and Thompson7 Clavien et at. Davies et al. Saltzstein et al. Herzog et a/.'' Morgenstern et al. l 2 Cox et a/.l 3 Roslyn et al. l4 Raute et a/.l5 Harte et al. I h Gilliland and Traverso17 Gouma and GoIX Total 1976-1985 1978-1983 1982- 1990 360 1035 384 1984-1989 1985-1990 1988-1990 1984-1990 1982-1988 1985-1989 1989 1972-1991 1973- 1978 1982-1987 1088 630 500 1357 980 457 42 474 7057 390 671 1991 Bile duct injury 8 780 66 163 ~ Values in parentheses are percentages gastrointestinal tract or biliary fistula, and the authors therefore concluded that this was likely to be an overestimate of the true bile duct injury rate. The highest reported incidence was in the 1991 national survey in the Netherlands by Gouma and Go1s, in which there were 45 injuries in 8780 open cholecystectomies, of which 18 (0.2 per cent) required hepaticojejunostomy. Five patients needed end-to-end anastomosis, three strictures required endoscopic stent insertion and 15 injuries were closed primarily without T tube drainage (in four the treatment was not specified). Four of the 45 patients died as a consequence of the bile duct injury. In the report by Raute et al. of 16 (0.2 per cent) bile duct injuries in 7057 open cholecystectomies performed over a 20-year period, only three (0.04 per cent) required hepaticojejunostomy; the management in the others consisted of end-to-end anastomosis in three, T tube insertion in eight, endoscopic stricture dilatation in one and percutaneous or nasobiliary drainage in one. One patient initially treated by T tube drainage subsequently required hepaticojejunostomy. The final outcome of repair was good in all but one patient 307 308 A . J . M c M A H O N , G . F U L L A R T O N , J . N . B A X T E R and P . J . O ' D W Y E R with hepaticojejunostomy who had occasional episodes of cholangitis. Only one of the eight other bile duct injuries reported in the series shown in Table I required biliary reconstruction; the remaining seven were managed by T tube insertion (two patients), peritoneal drainage (three), suture of the laceration (one) and stricture dilatation (one). Incidence of laparoscopic bile duct injury Several early report^'^,^^, some of which were anecd ~ t a l ~ l suggested -~~, that laparoscopic cholecystectomy was associated with an increased bile duct injury rate compared with open cholecystectomy. In a series of 400 operations Troidl et aLZ0reported four (1.0 per cent) bile duct injuries, one of which resulted in death. TraversoZ3 reported 17 (2.8 per cent) common bile duct (CBD) injuries in a series of 597 operations. In 264 laparoscopic cholecystectomies performed in ten hospitals in the southeast of England, there were five (1.9 per cent) bile duct injuries, four of which required hepaticojejunostomyZ2. Smith2] interviewed biliary surgeons attending the American College of Surgeons meeting in 1991. All surgeons reported that bile duct injuries from laparoscopic cholecystectomy were occurring out of all proportion to those encountered at open cholecystectomy. From the first four surgeons interviewed Smith 'gleaned' more than 30 bile duct injuries. He went on to comment that for the non-specialist occasional cholecystectomist 'laparoscopic cholecystectomy was a recipe for disaster a keyhole scar and catastrophe within'. These increased risks have received coverage in the national press25. Perhaps the most important indicator is that specialist hepatobiliary units on both sides of the Atlantic have noted a dramatic increase in the number of referrals for management of bile duct injury2,22,26-30. Most single-centre series of more than 300 laparoscopic cholecystectomies have described a bile duct injury rate of less than 0.4 per cent, with an overall mean of 0.3 per cent15,31-47, although three series20.4s.49reported an incidence of 1 per cent or more (Table 2 ) . By contrast, 12 of 21 multicentre audit series described a bile duct injury rate greater than 0-4 per cent, with an overall mean of 0.5 per cent4.s0-66 (Table 3 ) . Two factors may explain this discrepancy. First, it is well recognized that bias occurs in the publication of a new procedure; serious complications and poor results are less likely to be mentioned67.Second, the single-centre series are gathered by surgeons who have performed large numbers of procedures and who are therefore far up the 'learning curve'; the majority of surgeons in audit series are probably lower on the curve. Taking both factors into account, an estimate across the surgical community as a whole of one bile duct injury in every 100-200 cases of laparoscopic cholecystectomy seems reasonable. Classification of bile duct injury Type of injury may be subdivided into bile duct laceration, bile duct transection or excision, and bile duct stricture. The level of stricture may be further graded according to Bismuth's classification6*(Table 4 ) . The rognosis of a bile duct injury depends on the nature of t e lesion. A small longitudinal tear, which is immediately repaired by primary suture or insertion of a T tube, has a quite different prognosis from completed division of the bile R Table 2 Bile duct injury in reported series of laparoscopic cholecystectornycontaining more than 300 patients from single centres No. of patients Reference KO and Airan3I Nottle32 Fitzgibbons et al.33 Wilson et ~ 1 . ' ~ Wolfe et al." Taniguchi et Lane and Lanthro~~~ Baird et al.3x Graffi~~~ Raute et a1.I5 Barkun et al.4o Soper et ~ 1 . ~ Clair et aL4Z Brown et aL4' Berci and Sa~kier~~ Davis et al.45 Graves et al.46 Perissat et at.47 Troidl et aLZ" Huang et al. 4x Kozarek et aL4' Total Bile duct injury 300 308 350 350 381 600 641 800 900 1022 1300 647 514 474 418 ~ 622 304 700 400 350 597 11978 Values in parentheses are percentages Table 3 Bile duct injury in multicentre audit series of laparoscopic cholecystectomy ~ ~ ~ No. of patients Bile duct injury Reference Place Litwin et aLSu Airan et aLS1 Cocks et al.sz Larson et aLs3 Devenys4 Dunn et al. ys Orlando et ~ 1 . Cuschieri et aLS7 McGee et aLSx Macintyre and Wilsonss* Southern Surgeons Club'" Deziel et aL4 Gigot in Suc et al.6" Kimura eta[." Trondsen et al. 62 Collet et al.63 Suc et at." Fullarton et aLM Go et aL6' Macintyre and Wilsonss* Kum and Goh66 Canada USA Australia USA Oregon, USA England ~ ~ Connecticut, USA Europe USA Switzerland 2201 2671 6 000 1983 9 597 3319 4 640 1236 950 1091 3 (0.1) 5 (0.2) 12 (0.2) 5 (0.3) 27 (0.3) 11 (0.3) 15 (0.3) 4 (0.3) 3 (0.3) 5 (0.5) USA 1518 7 (0.5) 77 604 3 244 365 (0.5) 16 ( 0 5 ) 1989 527 2 955 3 606 1655 6 076 2 888 11 (0.6) 3 (0.6) 18 (0.6) 25 (0.7) 11 (0.7) 52 (0.9) 26 (0.9) Total USA Belgium Japan Norway France France Scotland Netherlands Japan Singapore 1066 10 (0.9) 136816 634 (0.5) Values in parentheses are percentages. *Presented at the 3rd World Congress of Endoscopic Surgery, Bordeaux, France in 1992 British Journal of Surgery 1995, 82, 307-313 BILE DUCT INJURY IN LAPAROSCOPIC CHOLECYSTECTOMY Table 4 Bismuth classification”xof bile duct strictures Grade Description 0 1 2 3 4 5 Common bile duct Low stricture ( > 2 cm CHD) Middle stricture ( < 2 cm CHD) High stricture (confluence preserved) High stricture (confluence destroyed) Right anomalous duct CHD, common hepatic duct Table 5 Proposed definition of major and minor bile duct injury Major bile duct injury (at least one of the following present) Laceration > 25 per cent of bile duct diameter Transection of common hepatic duct or CBD Development of postoperative bile duct stricture Minor bile duct injury Laceration of CBD < 25 per cent of diameter Laceration of cystic-CBD junction (‘buttonhole’tear) CBD. common bile duct ducts above the bifurcation, which goes unrecognized and is repaired after a delayed interval. Therefore, a subdivision into major and minor ductal injury is proposed in Table 5. Minor injury can usually be managed by simple suture repair and/or insertion of a T Major injury usually requires h e p a t i c o j e j u n o ~ t o m y ~ ~ ~ ~ * ~ ~ ~ ~ ~ . 309 Laparoscopic bile duct injury tends to be more severe than that which occurs during open cholecyste~tomy~~. A portion of the duct is typically resected, the proximal level of the injury is high (Bismuth type 3 or 4) and the duct diameter is usually small, all of which make for a poorer prognosis after repair73. Causes of laparoscopic bile duct injury There are several reasons why the bile duct may be more vulnerable during laparoscopic cholecystectomy and the anatomy misidentified. The camera provides a monocular view from a direction quite different from that of open surgery; the CBD is not usually seen from this angle. Cephalad traction on the fundus compresses Calot’s triangle, while lateral traction on Hartmann’s pouch tents up the CBD, which may then be mistaken for the cystic duct, especially when that duct is very short. Another cause of greater risk is the use of diathermy around Calot’s triangle74; this is rarely used during open cholecystectomy. In the early days of laparoscopic cholecystectomy, laser technique was popular, particularly in the USA. There is anecdotal evidence that this is more dangerous than diathermy dissection since the laser beam may be applied inadvertently to the bile duct or past-pointing of the laser beam may O C C U ~ ~ It* ~has ~ . subsequently been shown that laser therapy offers no benefit over diathermy dis~ection~~ Its. use should certainly be avoided completely in Calot’s triangle. The laparoscopic ‘learning curve’ There is substantial evidence to suggest that the learning Types of laparoscopic bile duct injury curve has contributed to the high rates of bile duct injury. Several types of laparoscopic injury occur2,22*26-30,48,69,70. In the Southern Surgeons Club series59, the bile duct The classical one involves misidentification of the injury rate in the first 13 patients operated on by each common duct for the cystic duct: the common duct is clipped and divided, the common hepatic duct is resected and the proximal biliary tree clipped and divided (the right hepatic artery is usually also injured because of its proximity). A variant of the classical injury is seen when the CBD is clipped and divided distally and the cystic duct is correctly clipped and divided, leaving a complete biliary fistula. Another common injury occurs when tenting results in a portion of the common duct being removed between clips. This may cause stricture, complete obstruction or a fistula. A third injury occurs when the right hepatic duct is misidentified as the cystic duct, and clipped and divided. There is a suggestion that bile duct injury that occurs during laparoscopic surgery is less likely to be detected at the time of operation than that occurring during open cholecystectomy. In the study of Gouma and GoI8 55 per cent of injuries during open cholecystectomy were noted at the time, compared with 34 per cent during laparoscopic cholecystectomy. This has implications for prognosis, as delay in recognition reduces the chance of successful repair. Strictures may present weeks or months after laparoscopic cholecystectomy2. Most are thought to be due to injudicious use of diathermyz7,but some may result from partial obstruction by misplaced clips71. Duct laceration may be caused by diathermy or scissor injury. In most series the bile duct injuries have not been associated with aberrant anatomy26,29,48,72. British Journal of Surgey 1995, 82,307-313 surgical group was 2.2 per cent, compared with 0.1 per cent for subsequent patients. In the national survey of hospitals in the USA4, the average bile duct injury rate was 0.65 per cent in institutions that had performed fewer than 100 laparoscopic cholecystectomies, compared with 0.42 per cent at hospitals with more than 100 performed. Similarly, in the Connecticut state audits6, eight of the 15 bile duct injuries occurred during a surgeon’s first ten cases, five between cases 11-50 and only two after case 50. Of 17 biliary injuries or leaks reported by Kozarek et u Z . ~ ~ 13 , occurred within the first 20 procedures performed by the surgeon. In Davidoff and colleagues’ report of 12 bile duct injuries, ten occurred within the first 11 laparoscopic proceduresz7. Further evidence that the increased incidence of laparoscopic bile duct injury is related to the learning curve is contained in a report of 81 injuries from three tertiary referral centres70. The number of referrals peaked during 1991, and in 1993 declined to an incidence typical of the prelaparoscopic era. Data on open cholecystectomy are also worthy of note: in a report of 65 bile duct injuries, 55 (85 per cent) were inflicted by unsupervised surgeons in training77. The European Association of Endoscopic Surgeons has recently published guidelines on the minimum acceptable level of training before a surgeon be allowed to perform laparoscopic cholecystectomy unsupervi~ed~~. Among the conditions are attendance at a recognized endoscopic course, supervision during the first five procedures and written review of the results of the first ten operations. 3 1 0 A . J . M c M A H O N , G. F U L L A R T O N , J . N. B A X T E R and P. J . O ’ D W Y E R Role of cholangiography The development of laparoscopic cholecystectomy has rekindled a long-standing and unresolved debate about the value of routine cholangiography. Severa12s.48~79,so authors have suggested that the routine use of operative cholangiography might prevent bile duct injury. It is argued that it may help in further defining anatomy (particularly if it is aberrant) and, in the event of a bile duct already being injured, allow early recognition and immediate repair. Other a ~ t h o r s ~ ~have , ~ ~ contested ,~’ this view. In a review of published series of laparoscopic cholecystectomy, Macintyre et al. 55 found no correlation between the incidence of bile duct injury and the frequency of operative cholangiography. Barkun and cow o r k e r ~ performed ~~ a series of 1300 laparoscopic cholecystectomies, using operative cholangiography selectively in only 54 (4.2 per cent). Five bile duct injuries occurred (0.4 per cent), but the authors concluded that in only one of the cases would routine cholangiography have led to earlier recognition of duct injury. Andren-Sandberg et ~ 1described . ~ ~a series of 65 bile duct injuries occurring during open cholecystectomy, with operative cholangiography performed in 62 (95 per cent) of the cases: the bile duct was injured before cholangiography in 44 per cent of cases and after normal cholangiography in 53 per cent. Several who do not perform routine cholangiography have reported large series of laparoscopic cholecystectomies without major bile duct injury. Most surgeons in the UK (85 per cent) do not perform routine cholangiographys4 and some bile duct injuries are known to result from the cholangiography catheterIs. A large randomized trial has concluded that operative cholangiography need be performed during cholecystectomy only when clinical criteria suggest the presence of CBD abnormalities or when there is a need to clarify ductal anatomy8s,86. Avoiding laparoscopic bile duct injury Steps to avoid laparoscopic bile duct injury have been advocated by several a ~ t h o r s ~ ~ - * ~ ~ ~ ~ ~ ~ ~ ) . 1 Ensure an optimal view of the operating field. 2 Always dissect away from the gallbladder. 3 Minimum use should be made of electrocoagulation in Calot’s triangle (laser should be avoided completely in this area). 4 The anatomy of Calot’s triangle should be completely clear before the cystic duct and artery are clipped or divided. The junction between gallbladder neck and cystic duct should be clearly demonstrated. 5 The procedure should be converted early to open cholecystectomy if the anatomy cannot be safely identified or troublesome bleeding occurs. A number of different techniques are used to perform laparoscopic cholecystectomy (hook dissection versus blunt or scissors dissection, diathermy versus laser) with apparently equal success. A number of additional technical points have been suggested by several authors to help avoid laparoscopic bile duct injury, but are not used by all surgeons. 1 Use a 30” telescope that allows different angles of view, gives an en face view of Calot’s triangle, and often allows visualization of the CBD. Obtain maximum cephalic traction on the fundus of the gallbladder, which brings Calot’s triangle into view and reduces redundancy of Hartmann’s pouch. Retract laterally on Hartmann’s pouch, which opens out Calot’s triangle and creates a sharper angle between cystic duct and CBD. Dissect along the posterolateral aspect of the gallbladder to free the neck of the gallbladder from the liver bed. Keep dissection of the gallbladder close to its wall. As in open cholecystectomy, retrograde dissection is a useful technique if there is severe inflammation. Perform operative cholangiography if there is any doubt about the anatomy. Bile leak Bile leak after cholecystectomy may result in an intraabdominal collection, biliary fistula or biliary peritonitis, which is a life-threatening complication. It may arise from three sources: the cystic duct, a subvesical bile duct (duct of L ~ s c h k a ~or ~ , a~ bile ~ ) duct injury (the last usually being considered separately in the classification of complications). The subvesical duct of Luschka is a slender duct, 1-2 mm in diameter, which passes from the right lobe of the liver in the gallbladder fossa to join the right hepatic or common hepatic Because of its position and small size, it is particularly vulnerable during cholecyste~tomy~~. Anatomical studies, using resin casting, dye injection and histology of cadaver livers, have shown that a subvesical duct is present in about 30-50 per cent of patients, although endoscopic retrograde or operative cholangiography detects it in only 1.3 per cent”. The reported incidence of bile leakage after open cholecystectomy varies considerably. In several recent large audit series of open cholecystectomy, there were no bile Clavien et aLs reported four (0.3 per cent) leaks requiring reoperation in a series of 1252 open cholecystectomies. Morgenstern and co-workers’* reported six (0.5 per cent) leaks resulting in fistula in a series of 1200 cholecystectomies; all six resolved spontaneously. In a series of 196 cholecystectomies in which routine drainage of the gallbladder bed was used for an average postoperative duration of 6days, bile was noted in the drain fluid in 19 (9.7 per cent), but only one patient (0.5 per cent) required a second procedures7. The source of bile leakage after open cholecystectomy is often not positively identified but cystic duct leakage is thought to be extremely rare. Bile leakage occurs with greater frequency after laparoscopic cholecystectomy2n~42~49~61~6s~92 Wolfe et al. 3s reported five (1.3 per cent) clinically significant postoperative leaks in a series of 381 laparoscopic cholecystectomies; four were from the cystic duct, of which three required operation. Peck24reported nine (1.9 per cent) leaks in a series of 482 laparoscopic cholecystectomies, six of which were from the gallbladder bed. Walker et ~ 7 1 described . ~ ~ seven (2.7 per cent) bile leaks in a series of 264 procedures. Trondsen et aL6’ reported ten (1.9 per cent) bile leaks in a series of 527 laparoscopic cholecystectomies; four were from the cystic duct stump (all requiring laparotomy) and six from subvesical bile ducts (one requiring laparotomy). There are a number of reasons why laparoscopic cholecystectomy may be associated with a greater risk of a bile leakage. Clips rather than ties are used for the cystic British Journal of Surgery 1995, 82, 307-313 B I L E D U C T I N J U R Y IN L A P A R O S C O P I C C H O L E C Y S T E C T O M Y duct. Cystic duct leakage may occur if a clip becomes dislodged”, if a clip does not completely traverse the duct or if electrocautery injury results in delayed tissue necrosis of the cystic Leakage from injury to the cystic duct distal to securing clips has also been described”. During laparoscopic cholecystectomy the gallbladder is usually dissected from the liver bed with diathermy, whereas at open cholecystectomy this is usually done by blunt or sharp dissection. It is possible that the subvesical duct is at greater risk of accidental damage during laparoscopic cholecystectomy because of the depth of thermal injury caused by electrocautery dissection. Conclusion Laparoscopic cholecystectomy has been introduced into routine surgical practice with unprecedented speed. Its introduction has been marred by reports of a higher incidence of bile duct injury. While there is evidence to suggest that the incidence of bile duct injury is falling as surgeons gain greater experience with the laparoscopic technique, careful audit is required to establish the true risk of injury. Avoidance of bile duct injury may require more closely regulated supervision of trainee laparoscopists. The use of safe techniques for defining biliary anatomy and early conversion to open operation when the anatomy is unclear may also reduce the risk of duct injury. References 10 II 12 13 McMahon AJ, Russell IT, Baxter JN et ul. Laparoscopic versus minilaparotomy cholecystectorny: a randomised trial. Lancet 1994; 343: 135-8. Moossa AR, Easter DW, Van Sonnenberg E, Casola G, D’Agostino H. Laparoscopic injuries to the bile duct. A cause for concern. Ann Surg 1992; 215: 203-8. Moossa AR, Mayer AD, Stabile B. Iatrogenic injury to the bile duct. Who, how, where? Arch Surg 1990; 125: 1028-30. Deziel DJ, Millikan KW, Economou SG, Doolas A, SungTao K, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77604 cases. Am J Surg 1993; 165: 9-14. Vanderpool D, Lane BW, Winter JW, Bone GE. Cholecystectomy. South Med J 1989; 82: 450-2. Ganey JB, Johnson PA Jr, Prillaman PE, McSwain GR. Cholecystectomy: clinical experience with a large series. Am J SUT 1986; 151: 352-7. Wanvick DJ, Thompson MH. Six hundred patients with gallstones. Ann R CON Surg Engl 1992; 74: 218-21. Clavien P-A, Sanabria JR, Mentha G et ul. Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. Ann Surg 1992; 216: 618-26. Davies MG. O’Broin E. Mannion C et u1. Audit of oocn cholecystectomy in a district general hospital. Rr J Surg 1492; 79: 314-16. Saltzstein EC, Mercer LC, Peacock JB, Doughcrty SH. Twenty-four-hour hospitalization after cholccystectomy. S u q Gynecol Obstet I99 1 ; 173: 367-70. Herzog U, Messmer P, Sutter M, Tondelli P. Surgical treatment for cholelithiasis. Surg Gynecol O h t e t 1002; 175: 238-42. Morgenstern L, Wong L, Berci G. Twelvc hundrcd opcn cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992; 127: 400-3. Cox MR, Gunn IF, Eastman MC, Hunt RF, Hcinz AW. Rriti.shJournul of Surgety 1005, 82, 307-3 I3 311 Open cholecystectomy: a control group for comparison with laparoscopic cholecystectomy. Aust N Z J Surg 1992; 62: 795-801. 14 Roslyn JJ, Binns GS, Hughes EFX, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporaiy enaiysk of 42474 patients. Ann Surg 1993; 218: 129-37. 15 Raute M, Podlech P, Jaschke W, Manegold BC, Trede M, Chir B. Management of bile duct injuries and strictures following cholecystectomy. World J Surg 1993; 17: 553-62. 16 Harte PJ, Kinvan WO, Hennessy TP, Gaffney PR, Brady MP. Biliary surgery for benign disease: a study of 500 consecutive operations. Ir J Med Sci 1979; 148: 297-302. 17 Gilliland TM, Traverso LW. Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long-term relief of symptoms. Surg Gynecol Obstet 1990; 170: 39-44. 18 Gouma DJ, Go PM. Bile duct injury during laparoscopic and conventional cholecystectomy. J Am Coll Surg 1994; 253: 229-33. 19 Peters JH, Ellison EC, Innes JT et al. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients.Ann Surg 1991; 213: 3-12. 20 Troidl H, Spangenberger W, Langen R et al. Laparoscopic cholecystectomy: technical performance, safety and patient’s benefit. Endoscopy 1992; 24: 252-61. 21 Smith R. Injuries to common bile duct during laparoscopic cholecystectomy. BMJ 1991; 303: 1475 (Letter). 22 Shanahan D, Knight M. Laparoscopic cholecystectomy. BMJ 1992; 304: 776-7 (Letter). 23 Traverso LW. Endoscopic cholecystectomy: an Analysis of complications - comment. Arch Surg 1991; 126: 1197. 24 Peck JJ. Endoscopic cholecystectomy: an analysis of complications - see comment. Arch Surg 1991; 126: 3-12. 25 Lightfoot L, Rogers L. Keyhole surgery could double risk of damage to patients. Sunday Times 1993; 11 April: 5. 26 Rossi RL, Schirmer WJ, Braasch JW, Sanders LB, Munson JL. Laparoscopic bile duct injuries. Risk factors, recognition, and repair. Arch Surg 1992; 127: 596-601. 27 Davidoff AM, Pappas TN, Murray EA et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy.Ann S U 1992; ~ 215: 196-202. 28 Asbun HJ, Rossi RL, Lowell JA. Munson JL. Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention, and management. WorldJ Surg 1993; 17: 547-52. 29 Branum G , Schmitt C, Baillie J et ul. Management of major biliary complications after laparoscopic cholecystectomy. Ann S u e 1993; 217: 532-41. 30 Cates JA, Tompkins RK, Zinner MJ, Busuttil RW, Kallman C, Roslyn JJ. Biliary complications of laparoscopic cholecystectomy.Am Surg 1993; 59: 243-7. 31 KO ST, Airan MC. Review of 300 consecutive laparoscopic cholecystectomies: development, evolution, and results. Surg Endosc 1991; 5: 103-8. 32 Nottle PD. Laparoscopic cholecystectomy: an Australian view. Aust N Z J Surg 1992; 62: 150. 33 Fitzgibhons RJ Jr, Schmid S, Santoscoy R et (11. Open laparoscopy for laparoscopic cholecystectomy. Surg Lqurosc Endosc 1991; 1: 216-22. 34 Wilson RG, Macintyrc IMC, Nixon SJ, Saundcrs JH, Varma IS, King PM. Laparoscopic cholccystcctomy as a safe and cffcctive trcatmcnt for scvcrc acutc cholccystitis. RMJ 1992; 305: 304-6. 35 Wolfc BM, Gardincr BN, Lcary BF, Frcy CF. Endoscopic cholccystcctomy. An analysis of complications. Arch Surg 1991; 126: 1102-8. 36 Taniguchi Y, Ido K, Kimura K ct ul. Introduction of a ‘safcty zonc’ for the safcty of laparoscopic cholccystectorny. Am J Gustrocnterol 1903; 88: 1258-6 I . 37 I>mc GE, Lathrop JC. Comparison of rcsults of KTP/532 lascr versus monopolar clcctrosurgical disscction in laparoscopic cholecystcctomy. .I I,u~~uro~tidosc~ Surg 1003; 3: 200- 14. 38 Baird DR, Wilson JP, Mason EM ct ul. An early review o f 3 1 2 A . J . M c M A H O N , G . F U L L A R T O N , J . N. B A X T E R and P. J . O ’ D W Y E R 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital. Am Surg 1992; 58: 206-10. 39 Graffis R. Laparoscopic cholecystectomy: the Methodist Hospital experience. Surg Laparosc Endosc 1992; 2: 69-73. 40 Barkun JS, Fried GM, Barkun AN et al. Cholecystectomy without ouerative cholangiograuhv. Imulications for common bile duct injury and retained common-bile duct stones. Ann SUT 1993; 218: 371-9. 41 Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new ‘gold standard’? Arch Surg 1992; 127: 917-23. 42 Clair DG, Carr-Locke DL, Becker JM, Brooks DC. Routine cholangiography is not warranted during laparoscopic cholecystectomy.Arch Surg 1993; 128: 551-5. 43 Brown E, Hawasli A, Lloyd L. Laparoscopic cholecystectomy: morbidity and mortality in a community teaching institution. J Laparoendosc Surg 1993; 3: 13-18. 44 Berci G, Sackier JM. The Los Angeles experience with laparoscopic cholecystectomy. Am J Surg 1991; 161: 382-4. 45 Davis CJ, Arregui ME, Nagan RF, Shaar C. Laparoscopic cholecystectomy: the St Vincent experience. Surg Laparosc Endosc 1992; 2: 64-8. 46 Graves HA Jr, Ballinger JF, Anderson WJ. Appraisal of laparoscopic cholecystectomy. Ann Surg 1991; 213: 655-62. 47 Perissat J, Collet D, Belliard R, Desplantez J, Magne E. Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases. World J Surg 1992; 1 6 1074-82. 48 Huang S-M, Wu C-W, Hong H-T, Ming-Liu, King K-L, Lui W-Y. Bile duct injury and bile leakage in laparoscopic cholecystectomy. Br J Surg 1993; 80: 1590-2. 49 Kozarek R, Gannan R, Baerg R, Wagonfeld J, Ball T. Bile leak after laparoscopic cholecystectomy. Diagnostic and therapeutic application of endoscopic retrograde cholangiopancreatography. Arch Intern Med 1992; 152: 1040-3. 50 Litwin DE, Girotti MJ, Poulin EC, Mamazza J, Nagy AG. Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases. Can J Surg 1992; 35: 291-6. 51 Airan M, Appel M, Berci G et al. Retrospective and prospective multi-institutional laparoscopic cholecystectomy study organized by the Society of American Gastrointestinal Endoscopic Surgeons. Surg Endosc 1992; 6: 169-76. 52 Cocks J, Johnson W, Cade R et al. Bile duct injury during laparoscopic cholecystectomy: a report of the Standards Subcommittee of the Victorian State Committee of the Royal Australasian College of Surgeons. Aust N Z J Surg 1993; 63: 682-3. 53 Larson GM, Vitale GC, Casey J et al. Multipractice analysis of laparoscopic cholecystectomy in 1983 patients. Am J Surg 1992; 163: 221-6. 54 Deveney KE. The early experience with laparoscopic cholecystectomy in Oregon. Arch Surg 1993; 128: 627-32. 55 Macintyre IMC, Wilson RG. Laparoscopic cholecystectomy. Br J Surg 1993; 80: 552-9. 56 Orlando R, Russell JC, Lynch J, Mattie A for the Connecticut Laparoscopic Cholecystectomy Registry. Laparoscopic chofecystectbmy. A statewide experience.-Arih S ~ r g1993; 128: 494-9. 57 Cuschieri A, Dubois F, Mouiel J et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991; 161: 385-7. 58 McGee JM, Randel MA, Morgan RM et al. Laparoscopic cholecystectomy: an initial community experience. J Laparoendosc Surg 1992; 2: 293-302. 59 Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991; 324: 1073-8. 60 Suc B, Fontes Dislaire I, Fourtanier G, Escat J. 3606 cholecystectomies sous coelioscopie: registre de la Societe Francaise de Chirurgie Digestive. Ann Chir 1992; 4 6 219-26. 61 Kimura T, Kimura K, Suzuki K. et al. Laparoscopic cholecystectomy: the Japanese experience. Surg Laparosc Endosc 1993; 3: 194-8. 62 Trondsen E, Ruud TE, Nilsen H et al. Complications during 1 1 . . the introduction of laparoscopic cholecystectomy in Norway. A prospective multicentre study in seven hospitals. Eur J Surg 1994; 160: 145-51. 63 Collet D, Edye M, Perissat J. Conversions and complications of laparoscopic cholecystectomy. Results of a survey conducted by the French Society of Endoscouic Surgerv and Interventiond Radiology. Surg Endosc 1993; f: 334-K ‘ 64 Fullarton GM, Bell G and the West of Scotland Laparoscopic Cholecystectomy Study Group. A prospective audit of the introduction of laparoscopic cholecystectomy in the West of Scotland. Gut 1993; 34: S69 (Abstract). 65 Go PMNYH, Schol F, Gouma DJ. Laparoscopic cholecystectomy in the Netherlands. Br J Surg 1993; 80: 1180-3. 66 Kum CK, Goh PMY. Laparoscopic cholecystectomy: the Singapore experience. Surg Laparosc Endosc 1994; 4: 22-4. 67 Nahrwold DL. Laparoscopic cholecystectomy - invited comment. Arch Surg 1992; 127: 403. 68 Bismuth H. Postoperative strictures of the bile duct. In: Blumgart LH, ed. The Biliary Tract. Clinical Surgeq International. Vol. 5. Edinburgh: Churchill Livingstone, 1982: 209-18. 69 Roy AF, Passi RB, Lapointe RW, McAlister VC, Dagenais MH, Wall WJ. Bile duct injury during laparoscopic cholecystectomy. Can JSurg 1993; 36: 509-16. 70 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: 27-33. 71 Nenner RP, Imperato PJ, Alcorn CM. Serious complications of laparoscopic cholecystectomy in New York State. N Y State JMed 1992; 92: 179-81. 72 Ferguson CM, Rattner DW, Warshaw AL. Bile duct injury in laparoscopic cholecystectomy. Surg Laparosc Endosc 1992; 2: 1-7. 73 Blumgart LH, Kelley CJ, Benjamin IS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg 1984; 71: 836-43. 74 Park YH, Oskanian Z. Obstructive jaundice after laparoscopic cholecystectomy with electrocautery. Am Surg 1992; 58: 321-3. 75 Easter DW, Moossa AR. Laser and laparoscopic cholecystectomy. A hazardous union? Arch Surg 1991; 126: 423. 76 Hill S. Electrocautery is superior to laser for laparoscopic cholecystectomy.Am J Surg 1992; 162: 458. 77 Andren Sandberg A, Alinder G, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. Pre- and perioperative factors of importance. Ann Surg 1985; 201: 328-32. 78 European Association of Endoscopic Surgeons. EAES guidelines: training and assessment of competence. Surg Endosc 1994; 8: 721-2. 79 Sackier JM, Berci G, Phillips E, Carroll B, Shapiro S, Paz Partlow M. The role of cholangiography in laparoscopic cholecystectomy.Arch Surg 1991; 126: 1021-5. 80 Hunter JG. Avoidance of bile duct injury during laparoscopic cholecystectomy.Am J Surg 1991; 162: 71-6. 81 Ramesh GN, Duggal A, Vij JC. Successful treatment of postoperative pleurobiliary fistula by endoscopic technique. Gastrointest Endosc 1991; 37: 574-6. 82 Voyles CR, Petro AB, Meena AL, Haick AJ, Koury AM. A practical approach to laparoscopic cholecystectomy. Am J SUE 1991: 161: 365-70. 83 Dugois ‘F, Berthelot G, Levard H. Laparoscopic cholecystectomy: historic perspective and personal experience. Surg Laparosc Endosc 1991; 1: 52-7. 84 Macintyre IMC, Wilson RG. Impact of laparoscopic cholecystectomy in the UK: a survey of consultants. Br J Surg 1993; 8 0 346. 85 Hauer Jensen M, Karesen R, Nygaard K et al. Predictive ability of choledocholithiasis indicators. A prospective evaluation. Ann Surg 1985; 202: 64-8. 86 Hauer-Jensen M, Karesen R, Nygaard K et al. Prospective British Journal of Surgery 1995, 82,307-313 BILE DUCT INJURY IN LAPAROSCOPIC CHOLECYSTECTOMY 87 88 89 90 randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis. Surgery 1993; 113: 318-23. McQuillan T, Manolas SG, Hayman JA, Kune GA. Surgical significance of the bile duct of Luschka. Br J Surg 193% 7 6 696-8. Hobsley M. Intra-hepatic anatomy: a surgical evaluation. Br J SUR 1958; 45: 635-44. Foster JH, Wayson EE. Surgical significance of aberrant bile ducts. Am J Surg 1962; 104: 14-19. Healey JE Jr, Schroy PC. Anatomy of the biliary ducts within the human liver. Analysis of the prevailing pattern of branchings and the major variations of the biliary ducts. Arch SUQ 1953; 66: 599-616. British Journal of Surgery 1995,82,307-313 313 91 Pickleman J, Gonzalez RP. The improving results of cholecystectomy. Arch Surg 1986; 121: 930-4. 92 Walker AT, Shapiro AW, Brooks DC, Braver JM, Tumeh SS. Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation. AJR Am J Roentgen01 1992 158: 785-9. 93 Nelson MT, Nakashima M, Mulvihill SJ. How secure are laparoscopically placed clips? An in vivo and in vitro study. Arch SUT 1992; 127: 718-20. 94 Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg 1990; 160: 485-7. 95 Dunn D, Nair R, Fowler S, McCloy R. Laparoscopic cholecystectomy in England and Wales: results of an audit by The Royal College of Surgeons of England. Ann R Coll Surg Engl 1994; 76: 269-75.