Laparoscopic cholecystectomy, bile duct injury and the British and Irish surgeon

Laparoscopic cholecystectomy continues to attract controversy with regard to a perceived higher incidence of bile duct injury than in the open procedure. One possible cause for this is the trend away from intraoperative cholangiography previously considered an essential part of the open procedure. Under the auspices of The Association of Surgeons of Great Britain and Ireland, a questionnaire was sent to all its consultant fellows asking for details about their individual experience of the most serious injury, bile duct resection. In all, 1100 questionnaires were sent; 362 (33%) replies were returned. Of those who replied, 300 performed laparoscopic cholecystectomy as part of their practice. The experience of the respondents was divided into three groups; 19 surgeons had performed < 50 laparoscopic cholecystectomies, 53 between 50 and 100 and 228 had performed over 100. Ninety-five (32%) never performed intraoperative cholangiography, 167 (56%) on a selective basis and 38 (12%) routinely. In all, 58 bile duct resection injuries were reported by 48 surgeons. Of the bile duct resection injuries reported, 49 of 58 (85%) occurred when an intraoperative cholangiogram was not performed. These figures suggest that if the incidence of bile duct resection injury is to be decreased in laparoscopic cholecystectomy, the use of intraoperative cholangiography has an integral role to play.