BACKGROUND: Complete reports of biliary and vascular injuries after laparoscopic cholecystectomy are rare. STUDY DESIGN: Fifteen patients with complex laparoscopic cholecystectomy injuries underwent corrective operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. Five of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein occlusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobectomy. Corrective biliary operations consisted of common hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepaticojejunostomy (one case), right posterior hepaticojejunostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases). RESULTS: Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations. CONCLUSIONS: A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecystectomy

Dodson, SF

Iwatsuki, S

Madariaga, JR

Selby, R

Starzl, TE

Todo, S

English

PubMed

Name not available

Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries

D-Scholarship@Pitt

('., :SIR =261) 29 4 2 e'" ;rr.- , Jr: D~ t (:"J" ier IITAL: IS, "film. J., :.-order, ~pfefI 'eac-,and 0Cyte """" "n1rI-:e ,)4 ,. lile ~tlon <jTlll 'ee-'s l1lt alh lS r" D":~ ," '. i t '\ ~ 'j fi~~ " CORRECTIVE TREATMENT AND ANATOMIC CONSIDERATIONS FOR LAPAROSCOPIC CHOLECYSTECTOMY INJURIES Juan R. Madariaga, M.D., FAC.s., S. Forest Dodson, M.D., Rick Selby, M.D., Satoru Todo, M.D., PH.D., Shunzaburo Iwatsuki, M.D., PH.D., F.A.C.s., and Thomas E. Starzl, M.D., PH.D., FAC.S., Pittsburgh, Pennsylvania BACKGROUND: Complete reports of biliary and vas-cular injuries after Iaparoscopic cholecystectomy are rare. STUDY DESIGN: Ftfteen patients with complex lapa-roscopic cholecystectomy injuries underwent correc-tive operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. FIVe of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein oc-clusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobec-tomy. Corrective biliary operations consisted of com-mon hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepati-cojejunostomy (one case), right posterior hepaticoje-junostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases). RESULTS: Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations. CONCLUSIONS: A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecys-tectomy. J. Am. CoU. Surg., 1994, 179: 321-325. (:mIPRHIENSl\'E REPORTS of successful operative cor-rections of biliarv and vascular injuries caused hv laparoscopic cholecvstectomv are scarce (1-:\ l. This report was done to summarize our experi-ence inoperative corrections of biliary and vas-cular injuries after laparoscopic c holecystectoJl1\'. Frnm lilt' llt-panrntDni~ 01 Surgery, L'lli\'t'rSll\' 01 fDfffIhur~h Sc!uK,1 of ~"DdiClfltDK fDiEEIbllr~hK Repnnt rtDDlfitDpf~: Dr, Ilian R, \1adanaga. l'imhHr\!h rran~planl IllsUiule. :ltiOI Fiflh .. henut'. -lW Fall ClilllC. lDillshllr~hK 1',\ 1:,:!U, J21 MATERIALS AND METHODS From August 1990 to March 1993, 15 patients were referred to us for operative corrections of laparoscopic cholecystectomy injuries. Six patients were men and nine were women. Their ages ranged from 27 to 80 years, with a mean age of 50 years (Table 1). Thirteen of the 15 patients undenvent elective cholecystectomy for cholecystolithiasis and recent episodes of cholecystitis. The remaining two pa-tients (Nos. 8 and 14) had choledocholithiasis as well as cholecystolithiasis. The latter two pa-tients. and another with known cirrhosis of the liver. had elevated serum bilirubin levels at the time of cholecystectomy. Laparoscopic cholecystectomy was converted to an open procedure in four of the 15 cases, either because of bleeding (Nos. 7, 10, and 11), or because of severe inflammatory adhesions (No. 13). In these four. biliary du~t injury was rec-ognized and reconstruction was attempted at the time of cholecystectomy. However, in two (Nos. 7 and 10) of the four cases, the vascular injuries were not recognized fullv even during the open procedure. In the remaining 11 cases, the injuries were not recognized until later (Table I). The most common clinical manifestation of lap-aroscopic cholecystectomy il~jury was severe ab-dominal pain as a result of bile peritonitis (six cases), followed by fever and jaundice as a result of obstructive cholangitis (four cases). Bile leak-age through the drain signaled biliary compli-cations in two cases. Postoperative hYpotension was the result of bleeding from hepatic laceration in one case (:-.Jo. 12) (Table I). [n nine of the 15 cases, the occurrence of "erions complication was recognized within a week. However, in the remaining six. clinical manifestation were delayed as long as three months after cholec"stectomv. The time of re-lerral ranged from the dav 'of cholecystectomv 10 more than seven months later. Ali but two cases were retcrred to us within a month. Four 322 Journal of the American College of Surgeons . September 1994 . Volume 179 TABLE I.-CUNlCAL PRESENTATION operative treat71U'7lt &ftrrai RecognitIOn Conlln"SlOn Onset 0/ be/OTt rr/erral and ajtn-Patient No. Age. y Sex at LC to optn symptoms. d Symptoms and signs davs aJter LC Le. d -t2 \1 No :\0 3 Bile peritonitis :>lone IO " 27 F No :\0 3 Bile peritonitis :--lone 14 :'I. 61 M No :--10 1 Bile leak through drain :>lone 6 4. 26 F No :>10 14 Bile peritonitis Laparotomy. 20 24 ;; . 73 M No :-':0 21 Recurrent cholangitis :>lone 225 6. 60 F No :-':0 10 Jaundice. fever. bile :>lone 16 7. 73 F Yes? Yes peritonitis 1 GOT 6.798. GPT 4.916 Hepaticojejunostomy. 0 5 8. 67 M No :>10 2 Bile leak through drain. :>lone 2 9. 37 F No :>10 14 jaundice Cholangitis. jaundice Hepaticojejunostomy. 14 17 10 . 36 F Yes? Yes 6 Jaundice. fever. bile Laparotomv. stem. duct-to- 8 peritonitis duct. 6 II. -t6 M Yes Yes T-tube. duct-to-duct* right 0 hepatic artery repair. 0 12 . -t2 F No :>10 Bleeding :>lone I 13. 33 F Yes Yes None 0 14. 80 ;"1 No :>10 90 Jaundice :>lone 120 15. :H F No :-':0 14 Bile peritonitis. fever. :>lone 27 subhepatic abscess • DIICH(Hiucl. cnd-to-end choledocho-cnoledochostom\·. I.e. l.aparoM'''pic cholec\'lltectomv; GOT. ghnamine·oxaloacetic transaminase; GPT. glutamic-pYruvic transaminase; y. year. and d. day. patientc; (Nos. 7, 9, 10, and 11) had unsuccessful corrective operations before referral (Table I). In two patients (Nos. 7 and 10), it was not certain whether or not the injuries were recognized at the initial operation. RESULTS Biliary duct injury and operation roTTf'ction. Eleven of the I-! biliarY duct injuries occurred at the commoll hepatic duct (Table I; Fig. 1). Common hepaticojt:;jllllostomy with ROllx-en-Y reconstruc-lion was successful in seven of the 14 patients (Nos. :~K -!. S. 6. 10. 13. and 14). In two patients (Nos. 2 and 9). however. the cauterization injury extcnded above the common hepatic duct. Right anterior and left hepaticoj~junostomies were re-quired in these cases hecause the right posterior duct drained into the left duct. In the remaining Iwo patients (Nos. 7 and H). left hepaticoit:;jun-ostomv and right hepatic lobectomv were nec-essarv hecause the right hepatic artcrv was also i nad\'t'rtcn tlv ligated. Two of the I-! biliarv duct injuries (Nos. I and II) occurred at thc right hepatic ducl. and anot her (:'\:0. l!j) at the right posterior hepatic duct. Right hepalicojt:;junostomv in paticnt :'\:0. I and right postcrior hepaticojcjunosLOlllv in pa-ticnt :\0. l!j were successful. In patient ~oK It. IHl\H'\'cr. right and kft hepaticojejullostomies. were nccessarv because of necrosis of the com-mon hepatic duct. caused b\' the right hepatic .lrtelY IIIjUI\' (Table II: Fig. I). Vascular injury and operative correction. The right hepatic artery was inadvertently ligated in five of 15 cases (Table II; Fig. I). This arterial injury was associated with the common hepatic duct injury in four patients (Nos. 7, 8, 10, and 14) and with the right hepatic duct injury in one patient (No. 11). The ischemic injury to the right lobe of the liver and the injury to the bile duct were insignificant in two (Nos. 10 and 14) of the five cases. and common hepaticojejunostomv alone was successful. However, in two cases (:\05. 7 and 8). initial biliary reconstruction failed be-cause of ischemic injury. and right hepatic lobec-tomy with revision of biliarY reconstruction was necessary. The portal vein was also inadvertently occluded in patient No.7 and was reconstructed with an end-to-end anastomosis after thrombec-tomy. The right hepatic artery il~jury could be repaired with an arterial allograft in another case (No. 11), but, right and left hepaticojejunosto-mics. were necessarv because of hepatic duct ne-crosis. Se\'ere laceration of the cirrhotic liver near thc round ligament in paticl\( No. 12 might havc resulled from the pneumoperitoncum during lap-aroscopic c holecvstectomv. CUIII/J/imiums alif'T IJjJerativl' (()TTl'rtUlTI. Initial cor-rcctin~ operation was attempted before referral ill four palicllls. The common hepaticojt:;junos-IOIllV leaked and the right hepaLic lobe became lIecrotic bccause of inadvertent occlusions of tlw ri~hi hepalic ariel''' and thc portal vein in patient :\0. 7. oi~ht hepatic lobectollw and left hepat-t i 1 + > \Iadariaga et al.: CORRECTIVE OPERATIO:'l< FOR I.AIJAROSCOPIC CHOLEC\STECfOMY f~grolbp 323 TABLE IL-I0;Jl:RY. CORREC"TIVE OI'ERXIWE qobKAq~tbkq .. y~a RESl:LTS I'atimt So, II/juries I , Right ht'patic duct r:orr~ctitlr OfJf'TfltitlP trratmenl Right hepaticojejunostomv Right ant. Ilcpaticojcjunostomv. right post and left &suUs .\ &: W at 37 rna ,\ &: W at 35 rna :! , Common hepatic dllct :, , Common hepatic duct -1 , Common hepatic duct 5 , Common hepatic duct. hepaticodllodenai fistula 6 , Common hepatic duct hepaticojejul1ostoJllv Common hepatica jejunostomv Common hepaticojejllnostomy Common hepaticojejllnostomv Common hepaticojejllnostomy A & W at 22 IlIO A &: W at 19 IlIO A & W at 18 IlIO A & W at 17 mo A & W at 16 mo 7 , Common hepatic duct. right hepatic arlelV. portal vein. right hepatic lobe necrosis Right lobectomy, portal vein reconstruction, left hepaticojejllnostomy II , , , Common hepatic duct. right posterior duct. right hepatic artery, right hepatic lobe ischemia I) Right ant. and post. hepaticojejunostomv, left hepaticojejunostorny. A & W at 14 mo 2) Right hepatic lobectomy, left hepatico-jejunostomy, caudate hepaticojejunostomv 9 , Common hepatic duct Right am, hepaticojejunostolllv. Right post and kft hepaticojejllllostomv ,\ & W at 13 rno I () , Common hepatic duct. right hepatic <lrlelV, right (;omlllon hepaticojejllnostolllV A & W at 13 IlIO hepatic lobe ischemia. common duct ischemia 1\ , Right ht'patic dUel, right hepatic artery, right hepatic lobe ischemia Right hepaticojejunostomv. left hepaticojejunostomv, right hepatic artery reconstruction ,\ &: W at 12 mo 12 , Liver laceration. cirrhosis Repair laceratioll Died dav 11 liver failur~ 1:) , (;ommon lH'patic duct 14 , Common hcpatic cluct. right hepatic ancn' 1:; , Right posterior duct (:oll1mon hepaticojejllllostomv COJIIlllon hepaticojejllnostolllv Right (lost. hepaticojejullostomv A &: W at 10 mo ,\ &: W at \J IlIO A &: W at 6 mo ~K :ylie~ and \\"c:lI; ant.. anterior: post.. pEF~tt·riEFrK anti mo. month. icojejunostomy after portal vein reconstruction corrected these serious ir~juries (Fig. I). The hep-atic~jejunostomv became obstructed probably be-cause of cauterization injury or ischemic injury, or both. in patient No.9. In this case. the right anterior and the left hepaticojejunostomies (the right posterior duct draining into the left duct) were successful (Fig. I). Primary duct-to-duct anastomosis o\,er an internal stem was disrupted because of bile duct necrosis caused bv right hepatic arterv occlusion in two patients (Nos. I () and II). As the ischemia of the right hepalic lobe was mild. high common hepaticojejunostomv alone was successful in patient ~oK 10. In another patielll with significant ischemia (No, II). the righl poslerior hepatic arterv could be recon-struLled with an arterial allograft. and the right and left hepaticojejunostomies were sliccessful (Fig. I), There wcre t\\'o cases of biliary kakag<: ;lfler our correclive opel'ation. In olle palient E~oK ~FK there was kakage at the righl alllenor hcp-.lticojl:jllll{)S\OIIl\. which \\;IS successfulh' n'\'isct! (Fig, Il. [n another case E~oI K) the mclusioll of the right hepatic arten' was lIot rl'cogni/cd during Ihe combined right anterior and postcrior hcpaticojejullostoll1V and Ihe left hepalicojcjun-OSWIll\', The leakage frol11 the right dun ;lIIas-lomosis and Ihe ischemic necrosis of lilt' right hcp;\lic lobe wcre diagnosed three weeks LIter. rJlt' kit Ill'P;ltl('ojejullostoll1\' ;llld tilt' (.lll<latl' hepaticojejunostomy after the right hepatic lobec-tomy corrected the il~juries (Fig. I). There was a case of biliary ohstruction as a result of a retained stone 12 days after hepati-cojejunostomy patient No. :;. The stone was re-moved by a perclltaneous procedure. One patient had f~ltal hepatic bilure after re-pair of severe laceratioll of the cirrhotic liver. Transplantation of the Ih'er was planned. but the patient had hronchopneumonia. sepsis, and multiorgan failure bet()re an organ became avail-able. Patient No. I ~ died ten days after laparo-scopic cholecvstectomv. Follow"lIp evaluation. Except for the single death. all of the remaining 14 patients were alive and well with normal hepalic fllnction tests six to ~~i llIomhs after the linal corrective operation. ;IS of Septem bel' 1993 Crable II). DISCUSSION There ;lrc basicallv t hrcc lvpes of C\'stic duct llnioll to the bilian' svstCIll (Fig-. ~FK \Iost com-11lOllh'. the cystic drClKioill~ the (011111101\ hepalic duct helow the union of the right alld left hepatic ducts (Fig. ~a l. Occasionallv. \ he cystic duct en-Il'l'S till' righl hepatic duct above the unioll of the right and left hepatic ducts ami below that (II the right allterior and posterior hepatic duct-; \ Fig. ~hFI or it ellters Ihe rig-ht posterior duct. \,here Ihe rig-ht anlerior hepatic duct j()ins the it'lt hepatiC dun I Fig. ~EFI Rareh' dot,S the right , ·11 324 Journal of the American College of Surgeons • September 1994 . Volume 179 CASE 1 CASE 2 CASES 3, 4, 6, 13 ~y .. i HO ~IA~el RA,H. D.,., LHO ~it-rtr o~or~~ c1~ CASES 5,14 CASES oA~j/iel ~ D LHO , o~l ~ RPHD '.,. RPHO (fl -~ . ", [ }1 . ( CASE 15 CASE 7 CASE 9 CASE 11 RHO,'" " (E.' LHO " ~ -. ." ----r 1-1 ( Ep~epairF RAHD . LHO, LHO o~~~~fo/t{ , (RHA Repair) FIG, I. Diagrams of injuries and corrective operations, IUID. Right hepatic duct; RPHD, right posterior hepatic duct; RAIIf), right anterior hepatic posterior duct drain into the cvstic duct (-4-Y) , Eleven of the 14 biliaJ\l duct il~juries seemed to occur in the most common type A cystic duct lInlon. Two in occurred in patients with type B IInion. ,1Ild one in a patielll with the type (: lInion. The cystic duct is usually short and away from the center of the hepatic hilum in these variallt tYpes of unions. and the right hepatic duct or the right posterior hepatic duct may be easily mistaken as a cystic duct. The dUCl-to-<iuct anastomosis is not recom-mended lor iaparoscopic cholecystectomy injuries because t he\' arc generally associated with ex-tensive cauterization injuries, The cauterization ~adariaga et at.: CORRELiI\'E OPERATION FOR L\PAROSCOPIC CHOLEc\sTECfOMY INJURIES 325 L TYPE A TYPES TYPEC a b c FIG. 2. a, b, and c, Basic patterns of cystic duct union. CB, Gallbladder. RP, right posterior; RA. right anterior, and L, left. i~ury extended above the common hepatic duct in two patients, and two biliary-enteric anasto-moses were required in these patients. The cystic artery most often arises from the right hepatic artery, its course in relation to the duct is quite variable, and occasionally there are two cystic arteries. The blood supply to the ex-trahepatic bile duct is usuallv double, that is, from the hepatic artery, including the right he-patic artery, and from the gastroduodenal artery. These two blood vessels communicate well along the duct (l0, 11). The occlusion of one source is usually well tolerated by the duct. However, when the duct is completelv or nearly completely transected, the blood supply to a segment of the duct becomes insufficient. Additional cau-terization injury during laparoscopic cholecystec-tomv aggravates the duct ischemia. Therefore, even an isolated common hepatic duct transec-tion should be repaired by the hepatic~iejullos­tomv with ROllx-en-Y. Injurv of the right hepatic arterY is a well-rec-ognized complication of cholecystectomy. There were five cases of right hepatic artery occlusion in our series. In all of these five cases, significant bleeding was cncountered during the laparoscop-ic cholecvstectomv. The operation was converted to an open procedure in three of the fi\'e cases. L'nfortllnatel\" however, the arterial injury was Ilot recognizcd in anv of the five cases at Ihe timc of cholecystectomy. and it was undetected again ill two of them, c\'en during t he second operatioJl. III;\ch'ertent ligation of Ihe right he-patic arter\,. when accompanied with tlle dUel IUJUry, can result in the most complex compli-cation. as presented. Basic anatomic knowledge of the hepatic hilum, as discussed previously, will prevent serious com-plications of laparoscopic cholecystectomy. Should they occur, it will be of great assistance for the proper corrective operation. REFERENCES I. Rossi. R. L.. Schirmer. W . .J.. Braasch . .J. w.. and others. Laparoscopic bile duct injuries. Arch. Surg .• 1992. 127: 596-602. 2. Branum, G., Schmitt, (:., Baillie, .1 .. and others. Man-agement of major hiliarv complications after lapanl-scopic cholecvstectomv. Ann. Surg .• 1993. 217: 532-541. 3. Ress. A. Moo S.ur. M. Goo :'\OIgornev. D. ~1KK and others. Spectrum and management 01 major complications 0/ laparoscopic dlOlecvstectomy. Am . .I. SUI'g., 1993. I {iIi: fiK~!FD·Sfi9K 4. Hjonsjii, C. H. The topographv 01 the intrahepatic duct svstems. Acta Anat .. 1951, II: 599-615. 5. Healev . .I. E .• and Schrov. P. C. Anatomv of the biliarv ducts within the human liver. Analvsis 01 the prevailing pattern of branching and the major variations 01 the biliarv duct~K Arch. Surg.. 1953. tifi: 599-61 fi. (i. Couinaud. C. La chirurgie dll contluelll biliaire super-it'ur. In: Le Foie Etudes Anatomiques et ChirurglCales. Pp. -196497. Paris: ~fassonK 1957. 7. Ohto, M .. Ono. T .. Tsuchiva. Y .. and Saisho. H. Roentgenologic OInalOmv 01 the hiliar ... tract. In: Cho-langiographv and Pancreawgraph .... Pp. 37-41. Tokyo: Igaku-Shoiu. 197H. H. Champetier. , .. Da ... in. J. 1... l.cLOublon. C. and others. .\herrant hiliar ... dUClS (\;lSa abcITantiOl): surgical illl-plications. Anal. (Jin .. 191'12.1: U7- 145. ~1K Smadla. C ... llld BllImgan. II. H. The biliary tract OInd Ihe anawlIlv of hilialv exposure. In: Surgelv of the Liver and Biliarv rracl. I'p. 11·22. :\('w York: Churchill !.i\;ngstone. 19HH. 10. :\onhover. J. ~1K A ... llld Tl'rhlamhe . .J. .\ new look ,II Ihe anerial slIpplv 0/ the hik duct in man and its ,url,(ical implicOitions. lIr. J. Surg .. I ~FT9K titi: :179-:11'14. II. fnblancllc. J .. \Ilisoll. I\, F.. .llld :\orthover. J ~fK A. \11 1"lIt'lIut' h'ISis lor hili,lr ... ,t!'inures. Surger\'. f~Fe:yK '.11: :):2-:>7. 

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Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries

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