Editing Laparoscopic cholecystectomy (section)

== '''Complications''' ==

=== '''Bile duct injury (BDI)''' ===

* Occurs around 0.15-0.3%     (major bile duct injury around 1-4 per 1000)
* Strasberg classification     (previously used Bismuth, but this is more applicable to open     cholecystectomy)
* Note that vascular injury,     especially right hepatic injury, is common when bile duct injury occurs



Type A:

* Leakage of bile not related     to injury of the main bile ducts - either cystic duct remnant or ducts of     Luschka
* Cystic duct leakage can occur     from laceration of a small cystic duct, dislodgement of one of the clips     or ligatures on the cystic duct, ductal necrosis from cholecystitis, or     distal obstruction in CBD causing blowout of cystic duct remnant
* Clinically significant     leakage from ducts of Luschka is rare
* Can be managed by ERCP and     stenting, or sphincterotomy. Then remove drain in 3-5 days once output     settles. Remove stent in two weeks if the patient is asymptomatic, LFTs     are normal, and no ongoing leak at follow-up ERCP.

Type B:

* Occlusion of aberrant right     hepatic duct
* Can occur when cystic duct     drains into right hepatic duct
* Commonly associated with     injury to right hepatic artery
* Can remain asymptomatic for     years, then present with recurrent cholangitis and fibrosis of segment
* Diagnosis usually made by     ERCP/MRCP
* Treatment is surgical -     hepaticojejunostomy +/- resection of affected lobes

Type C:

* Transection of aberrant right     hepatic duct
* Can occur when cystic duct     drains into right hepatic duct
* Commonly associated with     injury to right hepatic artery
* Can be managed by ERCP and     stenting, or sphincterotomy. Then remove drain in 3-5 days once output     settles. Then repeat ERCP or do a HIDA scan to assess for ongoing leak. If     minor leak, may need sphincterotomy or replace stent for another month.
* Total endoscopic management     of bad type C injuries is difficult because a segment is disconnected

Type D:

* Lateral damage to CBD
* If identified     intra-operatively, repair over a T-tube
* Can often be managed with     ERCP, but need to monitor closely to avoid progression to type E injury
* If a larger circumference is     involved, usually require operation
* If recognised <48 hours,     can be managed by ERCP and stenting, or sphincterotomy. Then remove drain     in 3-5 days once output settles. Then repeat ERCP or do a HIDA scan to     assess for ongoing leak. If minor leak, may need sphincterotomy or replace     stent for another month, or hepaticojejunostomy.
* If recognised >48 hours,     often do PTC to drain proximal system, then plan for hepaticojejunostomy     after a few weeks

Type E:

* Types:
** E1 (Bismuth 1): Transection      >2cm from confluence
** E2 (Bismuth 2): Transection      <2cm from the confluence
** E3 (Bismuth 3): transection      in the hilum
** E4 (Bismuth 4): separation      of major ducts in the hilum
** E5 (Bismuth 5): type C      injury plus injury in the hilum
* Intra-operative transections     can sometimes be repaired end-to-end over a T-tube
* But MOST type E injuries     require repair with hepaticojejunostomy
* Usually present with jaundice     weeks to years after cholecystectomy
* If identified after     operation, '''PTC is useful''' to delineate intrahepatic ducts and the length of the     stricture. The liver can also be decompressed at the time.
* Some strictures or partially     occlusive clips will be amenable to dilation and stent insertion
* ERCP can be effective, but     high-grade strictures >1cm in length are difficult
* Strictures not amenable to     other methods will likely need an hepaticojejunostomy
* If unstable patient,     associated major vascular injury, delayed recognition or complex injury,     often would delay repair for several weeks.
* 'Classical' bile duct injury     shown below - misidentification of CBD as cystic duct, clipped and     divided, further dissection on left side of CBD, then second transection     of CBD/CHD to get back onto GB. Often occurs in association with RHA     injury.
*


Bile duct injuries - intra-operative considerations:

Strategies to reduce:

* Use critical view of safety     (CVS) to identify cystic duct and artery (should be able to get this 90%     of the time)
** Fundus retracted superiorly,      infundibulum laterally
** Only two structures      connected to lower end of GB - cystic duct and artery
* Be aware - if short or     non-existent cystic duct, easy to mistake CBD for cystic duct, especially     if over-zealous retraction
* If CVS can't be achieved,     subtotal cholecystectomy may be considered, which avoids dissecting in the     hepatocystic triangle.
* Use IOC in patients with     acute cholecystitis or a history of the same
* Use IOC if suspicion of BDI     or uncertain anatomy
* Pre-op risk stratify
** Male
** Older
** Chronic cholecystitis
** Obesity
** Cirrhosis
** Adhesions
** Emergency cholecystectomy
** Cystic duct stones
** Hepatomegaly
** Gallbladder/biliary cancer
** Anatomic variations
** Fistulae
** Limited surgical experience
** More severe acute      cholecystitis (as per TG)
* Mild acute cholecystitis (TG)     - perform lap chole within 72 hours

Warning signs

* Given that only 40% of bile     duct injuries are noted at time of operation, stay vigilant that things     are 'off normal'
* Common warning signs to look     out for:
** Standard clip is      insufficient to completely occlude the distal structure
** Persistent leakage of bile      from liver
** Identification of a 'second'      ductal structure
** 'extra' soft tissue adjacent      to porta hepatis
** Large artery coursing behind      the presumed cystic duct
** Sustained bleeding from area      medial to GB
** Excessive number of required      clips
** Inability to adequately      identify regional anatomic structures

Management:

* General principles
** Thermal injuries or those      complicated by ischaemia are harder to repair and a simple      intra-operative repair is less likely to work
* Intra-op diagnosis -     immediate repair is possible by HPB surgeon
** Convert to open?
** Assess extent of injury -      further characterise via IOC
** Discuss with HPB surgeon
*** If no capable HPB surgeon       is available to help, terminate the procedure, place drains in the GB       bed and the transected proximal duct if possible, wake up the patient       and ship them to an HPB unit
** Accessory duct leak - ligate      if <3mm diameter with segmental or subsegmental drainage. If >=4mm,      it is likely to drain multiple hepatic segments, and thus requires      operative repair.
** Partial BDI (Type E) -      repair over T-tube
** Divided/almost divided CBD -      end to end anastomosis, also with a t-tube (some sources suggest      anastamose over T-tube, some say put t-tube distally through separate      choledochotomy
*** Can't reoppose without       tension - Kocher's maneuvre will give extra length
** Gray's surgical anatomy says      if >50% circumferential damage, needs hepaticojejunostomy
** High injury - Roux-en-y      biliary enteric anastomosis (low threshold for referral to a tertiary      centre)
* Post-op diagnosis
** Discuss with HPB surgeon
** Aim to transfer to HPB      centre
** Arterial CT to exclude      hepatic artery injury
** If there is local      inflammation from a delayed recognition of bile duct injury with biloma,      staged reconstruction after drainage of the biloma and creation of a      controlled bile fistula

=== '''Post-op bile leak''' ===

* Presentation
** Suspect with malaise, ileus,      mild jaundice, abdominal distension, RUQ tenderness
* Source
** Cystic duct
*** Caused by insecure closure       or high-pressure system
*** Can present 0-10 days       post-op
*** Tends to cease       spontaneously
** Major bile duct injury
** Injured liver parenchyma
*** Minor and self-limiting
** Accessory bile duct (of      Luschka)
*** Originating in the right       hepatic lobe, and entering the GB directly
*** Rare, unpredictable and       easy to manage
** Anomalous bile duct
*** From right lobe to       confluence of main RHD and LHD
*** Rare, unpredictable and       difficult to manage
* Investigation
** USS - define extent of leak      (localised collection vs surrounding liver vs diffuse biliary      peritonitis). Also assess intra-hepatic ducts.
** CT can be used if necessary
** HIDA scan can delineate      leakage of radiotracer into peritoneum to confirm diagnosis
** ERCP can then be used to      determine the site of leak
* Treatment
** Drain in situ, draining bile
*** Assess the patient for       SIRS/sepsis
*** If abdomen is soft, the       patient is well, LFTs are normal, and no sign of sepsis - the leak is       well-controlled
*** Try to determine the source       of leak - reconsider the operation
*** Consider investigations -       HIDA can demonstrate flow of bile to abdomen, USS can exclude undrained       collections, and MRCP can exclude major bile duct injury
*** Most will dry up eventually       - consider discharging the patient with drain in situ and close       follow-up, even if initially high-volume output
*** ERCP and stenting can be       done for larger leaks that are not resolving, or become complicated
** No drain and you suspect a      bile leak, or undrained collection
*** Ultrasound or CT to find       the biloma - CT is generally easier and allows you to see anatomy, and       maybe exclude PE
*** Consider HIDA to prove the       leak
*** Leaks <24 hours -       consider re-laparoscopy and cystic duct closure
*** USS/CT-guided drain if       necessary (bile peritonitis, sepsis, ileus, etc). Drain can likely come       out in 3-5 days - as above.
*** ERCP and stenting in most       cases - usually resolves the leak immediately without the need to drain       the biloma. Should also be on broad-spectrum antibiotics.

=== Bleeding ===

* Liver
** Often due to close proximity      of middle hepatic vein and tributaries to GB fossa (seen in 10-15%)
** Usually occurs while      removing GB from liver
* Arterial sources
** Cystic artery - careful with      clips if actively bleeding - easy to clip right hepatic artery
** Can become evident      post-operatively as an acute haemodynamic decline requiring      resuscitation, transfusions, re-operation. Culprit is usually a dislodged      clip in that scenario.
* Port site bleeding
** If suspicion of haematoma -      USS.
** Rarely requires relook      laparoscopy

=== Bowel injury - 1-4/1000 ===

=== Post-cholecystectomy syndrome ===

* Persistent abdominal pain and     dyspepsia that persist after cholecystectomy
* Syndrome, not a single     pathological process
* Differential diagnosis:
** GIT: IBS, pancreatitis,      pancreatic tumours, pancreas divisum, hepatitis, PUD, mesenteric      ischaemia, diverticulitis, oesophageal disease, diarrhoea from continuous      bile flow (usually settles within a few weeks)
** Extraintestinal: intercostal      neuritis, wound neuroma, CAD, psychosomatic
** Biliary:
*** Early - biliary injury,       retained cystic duct, CBD stone, pancreatitis
*** Late - recurrent CBD       stones, bile duct stricutres, inflamed cystic duct/GB remnant, papillary       stenosis, biliary dyskinesia
*** Sphincter of Oddi       dysfunction
**** Type I - a/w visible        sphincter stricture - 95% have resolution after sphincterotomy
**** Type II - non-dilated duct        and variable LFTs, less certain response to sphincterotomy
* Exclude retained stone and     refer to gastro

=== Jaundice post lap chole ===

* Hopefully retained stone,     hopefully not a bile duct injury
* If bilirubin continues to     climb along with elevated liver enzymes, need to exclude BDI
* MRCP or ERCP depending on     facilities and expertise

=== Retained CBD stones ===

* The clear investigation of     choice is MRCP. It is sometimes wise to wait and follow the bilirubin     trend, to avoid exposing the patient to unnecessary investigations for a     stone that was going to pass anyway.
* ERCP and sphincterotomy for     impacted stone (non-resolution of symptoms, LFTs, or persistent stone on     imaging)

[[Category:HPB]]