Avoiding Complication Laparoscpy 2014 English

8/13/2019 Avoiding Complication Laparoscpy 2014 English

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Avoiding Complications in Laparoscopic Cholecystectomy

Avoiding Complications in

Laparoscopic Cholecystectomy

Daniel Ludi MD


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Objectives

Understanding the magnitude of the problem

Cause and prevention of misidentification injuries

What to do if you have an injury in the operating

room

What to do with an injury post op

How to protect your self in case of a litigation


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LHD

RHDRHA


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I never had a complication !!


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It is important to learn from our mistakes

But it is even better to learn from

somebody elses mistakes


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Incidence of Lap Chole Injury

LC carries a nearly two fold higher risk of

major bile, vascular, and bowel

complications (Australia)

Concomitant intestinal injury 15% (Mexico)

Fletcher Dr. Ann Surg, 1999:229;449-457Mercado MA, Curr Surg 2004:61:380-385


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US Incidence: 1989-1995

Probably under reported Publication bias

Voluntary reporting via publication

If National Registries are more accurate of

true incidence of CBDI, then risk is 10x

over open chole


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Between 34% and 49% of surgeons are

expected to cause such an injury during theircareer

Archer SB, BrownDW, Smith CD, et al. Bile duct injury during

laparoscopic cholecystectomy: results of a national survey. Ann

Surg 2001;234:549558; discussion 558559

Francoeur JR, Wiseman K, Buczkowski AK, et al. Surgeons

anonymous response after bile duct injury during cholecystectomy.

Am J Surg 2003;185:468475


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Surgical Experience

Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy:

results of a national survey.Ann Surg 2001;234: 549559.


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Surgical Experience

One third of surgeons reporting an injury in

either group reported that the injury occurred

afterhaving completed 200 cases

Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy:

results of a national survey.Ann Surg 2001;234: 549559.


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Bile duct injury should be regarded aspreventable, but over 70 % of surgeons regard

it as unavoidable

Francoeur JR, Wiseman K, Buczkowski AK, Chung SW,

Scudamore CH. Surgeons anonymous response after bile

duct injury during cholecystectomy.Am J Surg 2003; 185:

468475.


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Why Have CBD Injuries Increased?

Inexperience with laparoscopic techniques

and equipment & inadequate training

Inappropriate dissection methods Inadequate plan for conclusively identifying

the cystic duct and bile ducts

Resistance to performing IOC


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Hesitancy to convert to open chole

Lack of familiarity with top down technique

or partial cholecystectomy Lack of understanding of anatomy and

mechanisms of injury


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Poor visualization Use of zero degree scope

Inadequate use of hemostatic devices Visual misperception mirage

Human Error, cognitive psychology

CBD misidentified as cystic duct

Strasberg S, J Am Coll Surg, 2000, 191:661-667

Way L, Ann Surg 2003, 237:460-469


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Arterial anomalies

Two cystic arteries Posterior cystic artery

Lateral cystic artery

Superficial Rt. hepatic artery


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Avoiding Complications in Laparoscopic CholecystectomyAnatoma Arterial


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Avoiding Complications in Laparoscopic CholecystectomyAnatoma Arterial


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Dissection plane

Opening the Posterior Peritoneum


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North American ApproachDissection begins high

on the gallbladder

Lateral to cystic artery

Hug GB wall, extend

Peritoneal incisionsAnterior and posterior

To the liver edge


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Isolating The Cystic Artery


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Strasbeg Sm. Herti M Soper NJ An analysis of the problem of biliryInjury during laparoscopic cholecystectomy J Am Coll surg 180:101-25, 1995


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The Critical View of Safety


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idi li i i i h l


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Safe Cystic Duct Ligation

Clips: see tips, extended beyond width of duct

Wide or short duct Endoloop

Hand tied ligation

Suture closure

Gallbladder neck closure Endoloop

Running suture

Stapler

If insecure or unsure place drain

A idi C li i i i Ch l


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Predictors of Difficult Cholecystectomy

Urgent Cholecystectomy for Acute

Cholecystitis

The presence of AC is a risk factor for conversion= operative difficulty

Strongest predictors of difficulty Timing of surgery > 48hrs after the onset of symptoms

Leukocytosis>18K Others predictors

Palpable GB, Maleness, Age

A idi C li i i L i Ch l


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Elective LC

Major risk factor is thick GB wall-

especially thick and contracted GB

Other: Prior acute cholecystitis, multipleattacks of pain, maleness, age, obesity,

previous surgery

Conversion rates are much lower 3-5% Look for combination of variables

A idi C li i i L i Ch l


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Oteher Possible Concomitant

Problems

Cholangitis

Acute Pancreatitis especially in acutecholecystitis

Liver disease/Cirrhosis/Portal Hypertension

A idi C li ti i L i Ch l t t


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Rationale for Ductal Identification

1. Infundibular Technique

2. Identify Cystic Duct/Common Bile DuctJunction

3. Critical View Technique

4. Cholangiography



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Factors associated with failure of the

infundibular technique

Acute Inflamation Thick GB wall

GB distension Impacted stone

Severe Chronic Inflamation Thick GB wall

Impacted stone

Intrahepatic GB

Adhesions



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Rationale for Ductal Identification

1. Infundibular Technique

2. Identify Cystic Duct/Common Bile DuctJunction

3. Critical View Technique

4. Cholangiography



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When the critical view cannot be

achieved

Early IOC through GB

Top Down (French) Approach

Partial cholecystectomy

Convert to open Cholecystostomy tube



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Operative Cholangiography

Operative cholangiography significantly reduced

the risk of injury even after adjustment for age,gender, hospital type and, severity of disease

Fletcher DR et al. Ann Surg 229:449, 1999



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Reasons Why Routine IOC Does Not

Make a Difference

Bad technique or misinterpreted 80% read as nl when injury was present

Performed after clipping/cutting

Dont indentify thermal injury at time of op

Injury can occur later with false

interpretation and illusion

Tenting injury by clipping CBD

Carroll BJ, Surg Endosc, 1996:10:1194-1197



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Argument for Routine Intra

Operative Cholangiography Identifies injury intra-operatively when

interpreted correctly

Reduce severity, morbidity, late sequelai

and costs

11/12 injuries identified in 3,242 LCs All injuries Bismuth I,II 10 were primary repairs, 1 hepaticojejunostomy

Carroll BJ, Surg Endosc, 1996:10:1194-1197



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Risk Reduction with Routine IOC

Fletcher, Australia 50% reduction in 7,000 LCs

Flumm, Washington State 1991-97 67% reduction in 30,000 LCs

Flumm D, Ach Surg, 2001:136:1287-1292

Fletcher Dr. Ann Surg 1999:229:449-457



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Intra-Opertive Cholangiography

Medicare Pts, 112-99

1,570,361 cholecystectomies

7911 CBD injuries (0.5%) With IOC (0.39%)

Without IOD (0.58%)



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g p p p y y



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g p p p y y



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g p p p y y

When the critical view cannot be

achieved

Early IOC through GB

Top Down (French) Approach

Partial cholecystectomy

Convert to open

Cholecystostomy tube



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g p p p y y

Cirrhosis, Portal Hypertension and

Cholecystectomy

Does the patient need the operation?

Childs A only Lower portal pressure with drugs and have

veno-veno bypass available

The surgeon doing the operation should beexperienced in operating on patients with

portal hypertension and in doing

cholecystectomy



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g p p p y y

Completing a Difficult

Cholecystectomy without Completingthe Cholecystectomy

Cholecystostomy

Patial cholecystectomy With a tube

Leave back wall of GB in and close cystic duct

from inside. Ablating GB mucosa is an option.


Error trap 2


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g p p p y yError trap 2



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g p p p y y

Top Down, Partial Chole



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g p p p y y

Partial Lap Chole: Cirrhosis,

Portal HTN

This is safer than North American Technique

And can be sused in all patients



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g p p p y y

Endo Looping the Neck

Double Ligated Neck



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Should I convert to an open

procedure? To stop bleeding? Yes

To do the repair? Yes if within my skill set

To diagnose injury? Only if repair injury

To drain only? No



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Tipos de Lesiones

46 casos

15 transecciones

11 excisiones

6 laceraciones

8 lesiones por mala colocacin de los clips

3 lesiones con electrocauterio

2 fuga biliar del lecho hepatico y ductos aberrantes

1 fuga biliar a traves del cistico

B. J. Carroll Common bile duct injuries during laparoscopic cholecystectomy that result in litigation Surg

Endosc (1998) 12: 310314



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Common Scenarios In CBDI

80% not recognized at surgery

Cholangiograms misinterpreted 70%

Delay in Dx >5 days

Low success when repaired by primary

surgeon (25%) vs. experienced (80%) End to end fail in majority of pts

Carroll BJ, Surg Endosc 1998: 12:310-314



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Intraoperative Detection of CBDI

Convert to open, perform IOC When present-do correct repair of refer

Avoid primary end to end

RY hepaticojejunostomy for transection

High anastomosis

Mercado MA, Surg Endosc 2003, 17:1351-1355



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Can things be made worse?

The best chance for a lasting repair is the

FIRST repair.

Specialist HPB surgeons( individualscommonly doing bile duct and liver

resections) get better result in difficult

repairs (high injuries, small ducts, multiples

ducts, associated vascular injuries)



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Primary Surgeons successful outcome 27%

Referral Surgeons successful outcome 79%Carroll BJ, Surg Endosc 1998: 12:310-314

Can things be made worse?

Early Referral to a tertirary care center with experienced hepatobiliary

Surgeons would appear to be necessary to assure optimal resultsSurgical Management of Bile Duct Injuries Sustained During Laparoscopic Cholecystectomy

Perioperative Results in 200 Patients Jason K. Sicklick, MD(Ann Surg2005;241: 786795)

Surgeons who specialize in the repair of bile duct injuries

achieve muchbetter results than those with less experienceBile Duct Injuries During Laparoscopic CholecystectomyFactors That Influence the Results of Treatment

Lygia Stewart, MD; Lawrence W. Way, MD

Arch Surg. 1995;130(10):1123-1128.



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Timing of Repair

Immediate is preferred

Hence, intrao recognition is importat Increased chance of injury site control and

avoidance of bile peritonitis, obstructivejaundice

Reduce mortality, costs, LOS



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Diagnosing and Staging of Reapir

Influenced by type and time of recognition

Intraop suspicion Immediate post op

Intermediate post op (>2-5days)

Delayed (> 10 days

Chapman WC, J Gastrointest Surg. 2003, 7:412-416



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Intraoperative Detection of CBDI

Decision to refer to lack of experience

Obtain control of bile leak Intubate bile duct, externally divert Drain with close susction drains

Call receiving surgeon

Immediate transfer



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Immediate Post Op Detection

Establish DX Ralapasroscope < 24 hr

ERCP, HIDADecide if reoperation indicated vs non operative

management

Most injuries identified < 72 hr can undergo safe

immediate definitive repairDefer repair if septic or unstable



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More Delayed Injury (> 5 days)

Assure adequate surgical site control Biliary diversion

External draingage Treat sepsis

Delayed repair at 3-5 months

Major duct loss of tangential injuriesusually fail non operative treatment



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Treatment for Isolated Right Duct:

Strasberg Class C

Usually poorly dx by GI, ERCP

Requires experienced eye, demonstration ofall ducts by cholangiography

If clean and < 2 mm: ligate

If contaminated and/or > 3mm: consider RYhepaticojejunostomy



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Isolated Segment VI



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Isolated Segment VII:

Previously into Cystic Duct

VII



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Will carefull dissection alone solve the

problem of biliary injury?

OrDo we need to change

the

CULTURE OF CHOLECYSTECTOMY



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Changing the Culture of Cholecystectomy

Choletithiasis is a benign disease

A cholecystectomy never HAS TO BE

done in the face of severe inflammation

The benefit of completing a

cholecystectomy is a minor compared to the

benefit of avoiding a biliary injury



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We must teach not only how to avoid injury

but to avoid entering the zone of great

danger in which an injury can occur.

Changing the Culture of Cholecystectomy

This applies doubly when conversion occurs

and the problem becomes a difficult

OPEN cholecystectomy



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Oops! Just cut The Bile Duct!What do I Do Now?

Medico-Legal Aspect

15 % of all indemnity in general surgery is

from biliary injuries



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Preparedness

Be Prepared to Answer These Question BeforeStarting a Cholecystectomy

How to dictate the operative note when and

injury has occurred

How to refer the patient

How to discuss the injury with the patientand the family



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Operative Note

Dictate the note on the day of surgery when

memories are clearest.

Before beginning = jot down a list of the

point to be made

Describe the operative conditions clearly,

completely but without exaggeration

Include the rationale for cystic duct and

artery identification clearly

Describe consultations



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How to refer the patient

Call and speak to the accepting surgeon

Use HOLINES or Doctors Access Lines ifnecessary



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How to discuss the injury with the

patient and the family Present what is known about the injury, its

intended investigation and treatment in clear lay

terms (and pictures). Dont tell what you dont know or are not sure and

dont make judgmental statements

If referral is to be made tell patient that this

contact has been made personally, and provide the

name and area of interest of the accepting surgeon

to the patient.


Li i i


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Litigation

50% are litigated

Avg settlement: $ 1 million

80% settle in favor of plaintiff Difficult to defend for many reasons



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Factores Leading to Litigation

Complications resulting from delay in Dx

Treatment failures for immediately

recognized injuries

Failure to provide adequate safety net for pt

in post operative period Unavailability, inadequate cross coverage

Carroll BJ. Surg Edosc 1998: 12:310-314



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Results Following Repair of CBDI

85-95% initial success

Higher failure rate with concomitantvascular injury

Long term success: 80% when repair by

experienced surgeon vr 25%



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Avoiding Injury of the CBD

Dissect a triangle and NOT a duct

Be more liberal with IOC

When the anatomy is not clear convert When bleeding present do not cauterize or apply

clips blindly

Something is wrong if you need more than 8 clips


S


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Summary

CBDI are infrequent

Most are preventable

Early recognition results in best outcomes High repair is preferable for type E

If you lack experience with these repairs,

refer patient early

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Avoiding Complication Laparoscpy 2014 English