Bile duct injuries in open and laparoscopic cholecystectomy: Apples and oranges
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Bile duct injuries are potentially devastating for the patient and the surgeon. Most bile duct injuries probably occur during the initial 12-15 cases of laparoscopic cholecystectomy done by any one surgeon(8,15). It is imperative therefore that surgeons in training or who are new to this technique are adequately supervised during this period. There seems to be an increased incidence of bile duct injury with the laparoscopic technique (0.6% compared with 0.2%). Laparoscopic bile duct injuries however, may be more common but less serious compared with the open approach. A high proportion of laparoscopic injuries are injures in continuity, which may be managed without recourse to laparotomy. The incidence of severe injury requiring a hepaticoenterostomy does not seem to have increased, though as yet we cannot comment on the incidence of late duct strictures from the laparoscopic approach. Laser and diathermy injuries are also more common with the laparoscopic procedure and the high reported incidence of bile leaks must be carefully analysed.
It has been suggested that large scale audit is more likely to reflect the true incidence of bile duct injury due to under-reporting of a relatively uncommon problem in published series(43). Analysis of bile duct injuries should therefore take into account different rates in reported and audit series, bile leaks, probable increased primary diagnosis at the original laparoscopic cholecystectomy, and the learning curve as well as new mechanisms of diathermy or laser injury. With comparative analysis and experience the long term incidence of bile duct injuries may be similar to that after the open procedure, and indeed may even be less in some centres(50).
The mechanisms and gravity of biliary injuries may therefore differ with laparoscopic cholecystectomy and it is not surprising that approaches to treatment may differ also. It is not necessary to adopt the traditional common surgical approach with bilio-enteric anastomosis for all bile duct injuries occurring during laparoscopic cholecystectomy. This emphasises the importance of a multi-disciplinary approach to the investigation and management of bile duct injuries. As previously, it is advisable to refer these patients to a unit with a special interest in the management of bile duct injuries where, together with surgery, there should be access to endoscopy and interventional radiology with the whole range of percutaneous and endoscopic stents and balloon dilatation.
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