األية البقرة األية 32سورة البقرة 32سورة

Complications of laparoscopic cholecystectomy

By Prof.Dr.Ashraf Elzoghby

Most patients are discharged within 24 hours,recover rapidly,return to normal activity within 7 – 10 days.

Incidence: 0.5 % -5%

The most 2 common complications are :

1. Minor wound infections at port sites.

2. Intraoperative bleeding.

Wound infection :0.4 % -1.1 %Treatment : open the wound + antibiotics .Necrotizing infections are extremely rare.

Significant bleeding :<1%.Account for many conversions to open.Causes:

1. Trocar or Veress needle injury.

2. Liver lacerations.

3. From G.B. fossa.

4. Injury to cystic artery or P.V.

Trocar or Veress needle can be reduced by open technique to access the peritoneum.

Early recognition by hypotension & bleeding is essential.

Injury of epigastric vessels is reduced by lateral placement of trocars lateral to rectus sheeth under transillumination.

ttt: full thickness sutures or wound exploration.

Liver lacerations are decreased by:

1. Avoid excessive traction on G.B.

2. Avoid the flaciform ligament during epigasrtic port.

3. Meticulous dissection in the plane between the G.B. & liver.

Bleeding from cystic artery is controlled by suction ,irrigation ,cautery or clips.Conversion to open should not be delayed.Radiographs of cases of bile duct injury

show an unusual large number of clips.P.V. & Hepatic artery injuries

massive bleeding need laparotomy.

Early post operative complications

1. Spilled stones 3 -33%

2. Retained CBD stones 0.7 -1.5 %

3. Bile duct leak 0.4 -1 .1%

4. Bile duct injury 0.25-0.6 %

5. Bowl injury 0.2 -0.6 %

6. Incidental G.B. Cancer 0.35 %

Evaluation of Acute post operative problems

1. Persistent abdominal complaint ( pain, anorexia,nausea,vomiting & jaundice).

2. Evidence of infection (fever & chills).

CBC ,LFTs,amylase,lipase.Chest & abdominal X ray

atelectasis,pleural effusion.Small amounts of free air may be

present,but large amount of free air suspect visceral injury.

Ultrasound:quick & specific for fluid collection & percutaneous drainage.

C.T.: fluid collection.

Percutaneous drainage. MRCP: non interventional imaging of biliary

tree,retained stones,the pancreas,fluid collection.Not for percutaneous procedures.

HIDA scan:hepatobiliary iminodiacetic acid assesses hepatocellular function,flow of bile into duodenum,collection of extrabiliary radionuclide.

HIDA : can determine whether fluid collections originate from the biliary system,active leak,rate of leakage.

Does not precisely delinate biliary tree anatomy.

Can not differentiate between leak from biliary ducts & duodenal injury.

ERCP & PTC

Needs expert gastroenterologists or radiologists. Invasive means for diagnosis &treatment.ERCP : define biliary anatomy ,evaluate biliary

fistula ,perform therapeutic intervensions as draining the bile duct in the case of a cystic duct stump leak,extracting retained CBD stones,stenting or dilating strictures.

PTC:clearly define biliary anatomy,facilitate drainage of the biliary tree & stent placement.

PTC & stent can allow local control of the biliary fistula ,used as a landmark during surgery to identify transected ducts ( usually retracted into the hilum),aid post operative control of biliary leaks.

If sophisticated facilities,surgical expertise are not available for bile leaks,retained stones or injuries refere to tertiary centre.

Management of biliary injuries needs:

1. Define nature of injury from above(PTC) or below ERCP.

2. Percutaneous drainage.

3. Treating sepsis (antibiotics)&drainage.

4. Appropriate timing of expert repair.

Intra abdominal fluid collections may be bile,blood ,or enteric contents.

Some patients have post operative collections on C.T. not clinically significant.

Only 1% of all pts have clinically detectable leak.

Bile leaks are mostly due to bile duct injury or cystic duct stump leak.

Presentation not with peritonitis,but with pain,fever,malaise,jaundice,abnormal LFTs.

Prompt percutaneous drainage prevent sepsis,multi –organ failure send for culture &senstivity.

Then investigate the injury.

Spilled stones

Up to 30% of lap chole.Retained stones may lead to:abscess

formation,inflammtion,fibrosis,adhesions, cutaneous sinus & fistulae.(0.08% -0.3%

Retained stones or fragments may not lead to complications if bile is sterile,fragments are small& no other complications occur.

They encyst in fibrous capsule.

Spilled stones must be removed by copious irrigation & meticulous laparoscopic removal or conversion to open.

Spilled stones with infected bile can lead to abscess formation especially in elderly & immunocompromized patients than in young people in whom bile is usually sterile.

Abdominal wall abscess resulting from retained stones at port sites are treated with local drainage & evacuation of all stones.

Intra-abdominal abscess drained percutaneously if recurred ,suspect F.B. OR stones open exploration .

Gall stones have been found at hernial sac,urine &sputum.

Inform all patients.

Retained CBD stones

1.1% -3.3%ttt:endoscopic sphincterotomy & stone

extraction (± stent).Explore if :multiple large stones.

pt has Roux -en -Y gastric bypass, ,or Billroth II gastrectomy.

Biliary injury and leak

Significant morbidity.1% of lap.chole.Include leaks,strictures,transection or

ligation.

Biliary injury & Strasberg classification

Type A:leaks from cystic duct stump or minor ducts on liver bed with intact intrahepatic or extrahepatic ducts.

Leakage from cystic ducts may be due to:

Clip failure ( improperly applied or crossed clips or inadequate occlusion of the entire width of the cystic duct.

Burst phenomenon due to retained CBD stones.

Too tight application of clips local ischaemia & necrosis of the cystic duct.

C/P:

Abdominal pain ,anorexia,ileus,nausea,or bile peritonitis with sepsis ± jaundice (why)

HIDA scan contrast extravasation from the bile duct with radiocontrast also entering the duodenum.

MRCP : identify no therapeutic value .ERCP or PTC : extravasation adjacent to

cystic duct clips & provides therapy.

Management

Endoscopic transampullary stenting to decrease endobiliary pressure together with percutaneous drainage of localized bile collection.

Endoscopic sphincterotomy may be necessay in some cases to facilitate stent placement but may fail when used alone .

Non operative management succeeded in 90% Some may need laparoscopy to drain multiple bile

collections. Use straight plastic stent at least 7 F,removed after 4 weeks.

Open drainage is rare ,and surgical closure of cystic duct with clips or ligatures is hazardous in an oedematous and friable surgical field.

CBD stones must be removed by endoscopic sphincterotomy & stone extraction.

Type B

Occlusion of a portion of the biliary tree,when the cystic duct drains into the right hepatic duct.

The right duct or an aberrant right hepatic duct is mistaken for the cystic duct & is ligated or divided.

C.P.

May be asymptomatic as the obstructed lobe or segment atrophies & remaining liver hypertrophies.

Pain & cholangitis in the occluded area.If the main Rt or Lt duct are occluded

abnormal LFTS for long period with no functional consequences if the remaining liver is normal.

Type C

Leak from a duct not in continuity with the common duct(sectoral duct injury without occlusion),so bile leaks into the peritoneal cavity.

C/P: pain,nausea,vomiting,peritoneal irritation,signs of sepsis ±jaundice.

Distal stenting of this injury is ineffective.

May not be evident on ERCP if the distal clips are intact (no extravasation).

PTC may fail if the contralateral intrahepatic duct is entered and dye shows the proximal left and right hepatic ducts .

Diagnosed after establishment of fistula & dye injection into the fistula.

Type DLateral injury to any extrahepatic duct .By:

1. Cautery

2. Scissors

3. Improper placement of clips.o C/P:early with bile peritonitis.

late with stricture abnormal LFT ,jaundice ,cholangitis and sepsis.o Diagnosis:by ERCP or PTC after percutaneous

drainage of bile.

Type E

Excision or complete occlusion of CHD or CBD totally disrupts biliary enteric communication.

C/P:sepsis and peritonitis if bile is leaking or jaundice & cholangitis.

Management of biliary injury

Endoscopy:effective ,diagnostic & therapeutic for bile leaks.

Early use of ERCP is better.Sometimes ERCP is less therapeutic as in

type B,C& E injuries.

Bile duct injury during cholecystectomy require:

Bilioenteric anastomosis via ROUX –en –Y hepaticojejunostomy.

Direct primary repair with a stent(less common )only in selected cases:

1. Ends of bile duct are healthy.

2. Free of cautery or crush injury.

3. Have adequate blood supply ( no injury to hepatic artery or the 3 O‘clock and 9 O‘clock supply.

If there is excision of a significant portion of the bile duct ,primary repair over a T tube may result in excessive tension and later leak or stricture.

Type B injuries

May not require operative repair.Infection of a minor obstructed segment

Antibiotic ± percutaneous drainage.

If abscess rare & need resection depridement.

If the major Rt hepatic duct or two or more subsegmental branches Roux –en –Y hepatico jejunostomy

Type C

If it is a small sectoral right branch simple percutaneous drainage (then fibrosis of the duct atrophy of the subsegment.

If major Rt duct Roux –en – Y hepaticojejunostomy.

Type D

If with bile leak percutaneous drainage untill the patient is stable,non septic & with good pre-operative delineation of the anatomy.

Preop. Placement of PTC drain helps biliary drainage & identification of duct system.

Tangential injuries Roux –en- Y ( as primary repair is virtually impossible).

Injuries that almost transet the bile duct are best treated by complete division + closure of the distal end & Roux –en-Y .

If late with stricture Roux –en- Y hepaticojejunostomy

Type E

Roux en –Y-hepatico jejunostomy after drainage,delineation of anatomy,ttt of sepsis & inflammation.

If the bifurcation is involved (E4) two or more hepatic duct anastomosis ( left duct approach).

Timing of biliary injury repair

Early repair:early recognition ( intra-operative). Significant cost saving,decreased morbidity and

mortality,shorter hospital stay,decreased outpatient visits,minimize hepatic damage,avoid cirrhosis.

Delayed repair is indicated in unstable patient with sepsis.

Control bile leak by percutaneous drainage with PTC& external drainage and control sepsis & inflammation.

It is difficult due to hilar plate retraction,rotation of hepatic pedicle.

Transfer the patient to a tertiary center where an experienced surgeon ,radiologist ,gastroenterologist ,intensive care facilities.

Bowl injury

1.3 in 1000Commonly duodenum ,followed by

colon,stomach,small bowl.With trocar insertion,sharp instruments,shearing

of tissues during dissection of adhesions,thermal injuries,Veress needle.

If recognized during operation laparoscopic primary repair is safe or convert to open.

If late diagnosed by C.T.,oral contrast, percutaneous aspiration by U/S exploration.

Incidental G.B. cancer

0.5%Most are early lesions detected by

pathology.Laparoscopy for G.B. cancer is

controversial for port site Mets,peritoneal seeding and inability to attain adequate resection margin.

T1 a lesions ( invades lamina propria) simple cholecystectomy.

T1 b lesions ( invades muscular layer) may be cured by cholecystectomy but may need port site,liver bed and regional lymphadenectomy in a 2nd radical operation.

T2 invades perimuscular C.T. but does not extend beyond the serosa or into the liver 2nd radical operation.

T3 ,T4 perforate the serosa & extends into peritoneal structures & adjacent organs palliative 2nd radical operation to prolong survival.