Laparoscopic Cholecystectomy and Increased Risk of Bile Duct Injury
There are anatomical variations of bile ducts and blood vessels which may excuse the occurrence of a bile duct injury in a given case, but in general, an injury to the bile duct occurring during the course of a laparoscopic cholecystectomy, which injury results in recurring problems with the potential for permanent liver damage should be considered a case of possible medical negligence until proven otherwise.
With the increasing popularity of laparoscopic cholecystectomy in the United States, an appropriate and even preferred alternative to open cholecystectomy, we find unintentional bile duct injuries associated with a laparoscopic procedure occurring at twice the rate of similar injuries with open procedures.
Some believe that as experience with the laparoscopic cholecystectomy increases that the incidence of common bile duct injuries associated with the technique will diminish. Others dispute this.
A laparoscopic cholecystectomy is performed without need of the large abdominal incision required to otherwise perform the procedure. The open procedure is not only a major abdominal operation but is associated with prolonged recovery, scarring and pain.
The laparoscopic cholecystectomy permits the removal of the gallbladder through a small hole placed in the abdominal wall. The performance of the procedure requires that several small holes be placed in the abdomen through which instruments are introduced so as to manipulate the gallbladder and control those devices needed to divide the gallbladder from the cystic duct and to separate it from its attachment to the liver.
The principle difference from the surgeon’s perspective between a laparoscopic procedure and an open procedure is the lack of a three-dimensional view of the structure to be manipulated. During a laparoscopic procedure a surgeon is guided by a two-dimensional image seen on a television screen. This has a very different look and feel to the view that is obtained when one opens the abdomen and exposes the gallbladder directly. Depth perception is affected. Operating instruments at a significant distance from the point of application requires a higher level of coordination that would be necessary for a surgeon operating during an open procedure.
Notwithstanding the limitations of a laparoscopic cholecystectomy from the surgeon’s perspective, there are certain profound advantages to the patient. The quantity of tissue needlessly damaged simply to secure a view of gallbladder is completely eliminated. Though the view by television is two dimensional, the view is dry and clear. The abdominal wall is raised by inflation of air into the abdomen so that it appears to the laparoscopist as a dome. It is like watching some surgical contest being performed in an empty arena and at its center a generally green lustrous gallbladder as a target.
One wonders then how bile duct injuries occur so frequently when the laparoscopic procedure is employed. There is a specific technique that must be utilized during a laparoscopic procedure in order to assure the surgeon the best opportunity to identify the cystic duct (that duct connecting the gallbladder to the common bile duct) and the juncture of the cystic duct and the common bile duct. The area where the ducts connect is covered with gauze-like tissue and if this tissue is not dissected in order that the actual connection between the cystic duct and the common bile duct can be seen, serious mistakes are made. The chance of error is greatly magnified by the fact that the cystic duct normally varies greatly in length. It can be very short. It can be very long. The surgeon can look at one part of the cystic duct and then think they are looking at part of the common bile duct.
In general, when appropriate surgical safeguards are employed in the performance of a laparoscopic cholecystectomy there is no unintended injury to the bile ducts. Unintended injury to the bile ducts when it occurs is often a result of doctors having failed to employ those safeguards deemed appropriate for the performance of such a procedure.
First and foremost, if the doctor doesn’t have a clear view of the tissue they are about to divide, they should not divide the tissue. If the patient, because of their unique anatomy and shape is a difficult case, they should be converted to an open procedure.
Though it is true that there is much in the way of surgical literature suggesting that injury to a common bile duct is an “accepted complication” of the procedure, the statements are simply not true. It is true that injury to the common bile duct is a known complication of the performance of either an open or closed cholecystectomy. There is almost always a reason why such injuries occur and the injuries when they occur are often due to medical malpractice.
Injured bile ducts are not inconsequential complications. Even when promptly recognized and repaired, the injury to the common bile duct or common hepatic duct can result in a narrowing of the duct which can cause obstruction of the flow of bile out of the liver. The worse case scenario is the patient who ultimately requires a liver transplant because of a needless injury high in the biliary system during the course of a laparoscopic cholecystectomy. There are anatomical variations of bile ducts and blood vessels which may excuse the occurrence of a bile duct injury in a given case, but in general, an injury to the bile duct occurring during the course of a laparoscopic cholecystectomy, which injury results in recurring problems with the potential for permanent liver damage should be considered a case of possible medical negligence until proven otherwise.