Laparoscopic bile duct injuries: a single‐institution experience spanning 8 years

Background: This audit represents the authors' experience in the management of 42 bile duct injuries following laparoscopic cholecystectomy and is the largest series reported so far in the UK. Methods: Between November 1990 and May 1998, 42 patients were referred for management of bile duct injury following laparoscopic cholecystectomy. The case notes of all patients were reviewed and follow‐up information was obtained to provide a 100 per cent follow‐up rate. Aspects of the cholecystectomy, presentation, investigation, definitive treatment and follow‐up are discussed. Results: The referral source was 25 surgeons from 17 different hospitals. The incidence peaked in 1992 (ten cases) and has been stable at four referrals per year over the past 4 years. The median age was 56 years and the M: F ratio 10: 32. Thirty‐five laparoscopic operations were performed by consultants and seven by trainees. Intraoperative cholangiography was performed in three. Seventeen operations were converted to an open procedure because of intraoperative difficulty. Injury was noted at operation in nine and an immediate restorative procedure was attempted. Twelve patients had had a reconstructive procedure before referral to this unit and the remainder were referred with a fresh injury. Patients in whom the bile duct was transected ( n = 34) presented mostly with jaundice; those with minor injuries not involving the common duct ( n = 8) presented with peritonitis. Thirty patients required operation; 25 underwent hepaticojejunostomy reconstruction, two needed revision of a previous biliary–enteric anastomosis, two had primary bile duct repair over a T tube and one required relaparoscopy to clip a leaking cystic duct. At a median of 12 months four patients who had had a reconstruction were symptomatic for cholangitis. Percutaneous transhepatic dilatation was successful in two and a further two required revision of the anastomosis. Another four patients had asymptomatic stenosis and were treated successfully by a single episode of dilatation. Follow‐up showed all patients to be asymptomatic at a median follow‐up of 42 months; however, six had a raised level of alkaline phosphatase. The remaining patients were managed successfully by therapeutic endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. The overall median hospital stay was 18 days. Perioperative complications were seen in nine patients with no procedure‐related deaths. Conclusion: Although the initial learning curve seems to have been overcome, a steady state of problems now exists and seems likely to continue. Best results were obtained by hepaticojejunostomy. Most postrepair strictures were dealt with without operation. © 1999 British Journal of Surgery Society Ltd