Spectrum and management of major complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the most prevalent method of treating uncomplicated, symptomatic cholelithiasis in the United States and elsewhere. As experience with this procedure grows, certain pitfalls are becoming apparent. Since October 1990, we have treated 22 patients for major injuries incurred during laparoscopic cholecystectomy, including 15 women and 7 men (range: 23 to 85 years). One patient had previous upper abdominal surgery; no other patient had any relative contraindication to laparoscopic surgery. The most frequent site of injury (19 patients) was the extrahepatic biliary tract. There was one fatal duodenal perforation. All but two patients whose injuries went unrecognized at laparoscopy were symptomatic during the immediate postoperative period. The biliary injuries included complete transection of the common hepatic or common bile duct in 10 patients, complete ductal occlusion in 3, a cystic duct stump leak in 2, and a partially retained gallbladder with a contained intraperitoneal bile leak in 2. The site and extent of biliary injuries were delineated with transhepatic or endoscopic retrograde cholangiography. Reconstruction or repair of the biliary tract was accomplished with Roux-en-Y hepaticojejunostomy or cholangiojejunostomy in 11 and 1 patients, respectively, completion cholecystectomy in 2, and temporary transhepatic stenting, primary choledochocholedochostomy, and primary choledochorrhaphy over a T-tube in 1 patient each. One patient with a cystic duct stump leak was managed successfully with endoscopic sphincterotomy, whereas another required operative ligation. Laparoscopic injuries during cholecystectomy can lead to serious morbidity and mortality, thus emphasizing the need for adequate training and credentialing for surgeons and for a heightened clinical awareness of the potential complications, their long-term sequelae, and how to avoid them.