Laparoscopic cholecystectomy bile duct injuries: more than meets the eye

Laparoscopic cholecystectomy (LC) has rapidly become standard treatment of symptomatic cholelithiasis. Its advantages are well known, while its risks have not been well defined. The most common major complication of LC is bile duct injury. Over the past year, we have treated six patients for this problem. Injuries included: one partial laceration of the common bile duct; one partial laceration of the common hepatic duct; three complete common hepatic duct transections at the bifurcation, and one clip obstruction of the right hepatic duct. Intraoperative cholangiography was performed in two of six patients. Injury was recognized in these two cases, which were converted to celiotomy for immediate repair. One was repaired primarily; the other required a hepaticojejunostomy. Injuries were not identified at LC in four. Three of the four patients required biliary-enteric reconstruction procedures. With a mean follow-up period of 13 months, four of six patients remain symptomatic. LC does carry a real risk of bile duct injury. Routine intraoperative cholangiography may decrease this risk or at least allow early recognition and repair when it has occurred. Conversion to an open procedure is not a complication of LC but rather a sign of good surgical judgement. Patients not following the routine postoperative course must be evaluated for a possible bile duct injury to prevent the morbidity of delayed diagnosis.