Bile duct inuries in laparoscopic Era Prevention Detection Management

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Faiez    on Dec 01, 2010 Says :

Very good and informative presentation DR.Faiez Hmoud- Cons. Surgeon
kurikala    on Nov 25, 2010 Says :

very good presentation,with all prespectives classifications,variations,tips for prevention .,Dr.K.Raghu.,asst.professor.,KMC Warangal.A.P.,India
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Slide 1 : BILIARY DUCT INJURY(POST operative)Prevention ;Detection; Management DR Fiaz Maqbool Fazili Acute Care and Laparoscopic surgeon
Slide 2 : Amount of gall bladder surgery Cholecystectomy is a commonest elective abdominal operation all over the world/KSA/King Fahad hospital Medinah also. In 1992 it was estimated that 10-15% of adult population of USA had gall stones ..ABOUT ONE MILLION PTS ARE NEWLY Diagnosed annually and approximately 600,0000 pts underwent cholecystectomy in 1991 .
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Slide 5 : Introduction During the past years laparoscopic cholecystectomy has been generally accepted as the treatment of choice for symptomatic gallstone disease and has replaced the conventional "open" cholecystectomy. Several studies have shown the efficacy and safety of the procedure as well as the advantages as reduced hospital stay, earlier recovery, less intra-abdominal adhesions and a better cosmetic outcome
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Slide 9 : DRAWBACK ). Unfortunately this minimal invasive technique is associated with a higher incidence of bile duct injury ( BDI ) ( 5 ). It has been reported that the incidence of BDI is strongly related with experience and therefore an increase of experience will lead to a decrease of BDI today.
Slide 10 : Background The introduction of laparoscopic cholecystectomy (LC). as a viable and indeed the preferred alternative to the "gold standard" open cholecystectomy (OC) has brought forth a new sphere of complications. By far the most common source of these claims is related to injuries of the extrahepatic (outside of the liver) biliary tree, (the common hepatic duct (CHD) and the common bile duct (CBD).) These injuries include excision, division, narrowing and occlusion of these structures
Slide 11 : Incidence OF BDI The incidence of bile duct injury associated with laparoscopic cholecystectomy is reported to be twice that of open cholecystectomy (0-0.4% for OC and 0-0.7% for LC). As experience with laparoscopic cholecystectomy increases it is the impression of many authors that the incidence of common duct injuries associated with this technique is going down. Some experts dispute this and feel that the incidence of complications is still higher with the laparoscopic technique and in fact shows no signs of decreasing as was anticipiated_However the number of less severe injuries is seen more compared to severe Major TypeE. Also the interval between referral and injury is decreasing .(Changing referral pattern of biliary injuries during lap chole BR J surgery2000)
Slide 12 : WHY CBD INJURY IS SERIOUS PROBLEM? Significant injury to either one of these structures (CHD, CBD) may, and frequently does, represent a very serious complication. These injuries often require frequent reoperation or necessitate the use of various other invasive techniques to repair them and are thus a source of significant morbidity and on occasion mortality, not to mention the very great monetary expense to both patient, hospital and insurance companies. These patients frequently experience significant time away from work, loss of income, loss of employment. Also on occasion they may develop long-term medical problems related to these injuries. Two of the most serious medical problems being liver damage and the possibility of narrowing (stricture) of the repaired bile duct, especially if the injury is not managed correctly the first time.
Slide 13 : Causes of injury Anatomical anomalies-Topography Local pathology Technical aspects lack of tactile;3D vision;virtual image in laparoscopic procedures Human factors & Cognitive psychology Learning curve Beginner surgeon Over confident surgeon after 75-100 cases Lack of credentialing policy at some institutions
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Slide 17 : Variations
Slide 18 : Variations
Slide 19 : Variations
Slide 20 : Variations
Slide 21 : Variations
Slide 22 : Variations
Slide 23 : Need to know Classification of Biliary injuries Purpose=To know the severity of damage Communication purposes between Doctors or centers (periphery to higher centers) Treatment purposes-modality of treatment Types of calssification(commonly used) Bismuth classification Strasberg classification -McMohan
Slide 24 : Grades of injury Minor leak from injury to ductal system Major Ductal injury at hilum level with separation of liver parenchyma from the extrahepatic ductal system TO
Slide 25 : Biliary leak The leak may be a minor one arising from small, accessory bile ductand clinically insignificant; it may be treated by percutaneous drainage. Balija et alfound that lesions of the accessory bile duct are the commonest cause of postoperative complication. On the other hand a major leak] arising from injury to a main duct or retained stone in CBD results in biliary fistula, peritonitis or biloma
Slide 26 : Cystic duct injuries It is a common cause of biliary fistula following LC. Mostly results from improper application of clips and their slippage.[ Use of diathermy to divide the CD may cause the charring of tissue and failure of the clip to hold. ERCP helps in diagnosis, removes doubts regarding possible major ductal injuries. The condition resolves spontaneously[15] provided there is no distal obstruction; the process may be hastened by the placement of a stent endoscopically.
Slide 27 : Extrahepatic bile duct injuries Only 29% of the injuries are recognized per-operatively. The injury varies from partial tear of the bile duct to laceration, transection and even excision of a portion of the duct. They are seen irrespective of the type of cholecystectomy and result in biliary stricture which is undoubtedly the most serious complication following cholecystectomy. The severity of the complication depends on the type of injury, the delay in presentation and on whether the patient requires a revision of an initial attempt to repair. Injuries identified and repaired at the time of the first operation afford good results.[6]
Slide 28 : Extra hepatic bile injuries---cont In bile duct excision a portion of the bile duct is lost and simple repair, as may be done in transection and laceration is not possible. Chances of late stricture[16] are more in bile duct transection in comparison to laceration as the axial vascular supply of the CBD is damaged in a transected CBD. Biliary reconstruction in the presence of peritonitis, combined vascular and bile duct injuries, and injuries at or above the level of the biliary bifurcation were significant independent predictors of poor outcome
Slide 29 : Intrahepatic bile duct injuries These include injuries at or above the bifurcation of the CHD[17] and are more often seen with LC than with open cholecystectomy.[8] They may result following the "classic" injury described above or during the dissection of the gall bladder, with a fibrosed Calot's triangle, from its bed.
Slide 30 : Classifications The generally accepted classification of Bismuth for bile duct lesions used in many previous reports of strictures after open surgery is a classification according to the level of injury but unfortunately not to the nature of the lesion and can therefore not be used for all lesions (bile leaks) after laparoscopic surgery. Several new classifications for a bile duct injury have been reported during the past years.Strasberg & McMahon suggested in a review a more simplified definition by dividing BDI only into major and minor bile duct injury ( 5 ).
Slide 31 : Strasberg classification A_E
Slide 32 : Strasberg classification of laparoscopic injuries to the biliary tract. Type A injuries originate from small bile ducts that are entered in the liver bed or from the cystic duct. Type B and Type C injuries are most always involved aberrant right hepatic duct.Type A, C, D, and some E injuries may cause bilomas or fistulas. Type B and other type E injuries occlude the biliary tree and bilomas do not occur.
Slide 33 : Strasberg classification Strasberg et al made Bismuth's classification much more comprehensive by including various other types of laparoscopic extrahepatic bile duct injuries. The injuries were classified from Type A to Type E. The latter, representing biliary strictures, has been further subdivided as per Bismuth's classification into E1 to E5. Type A injuries are bile leak from injured minor ducts like cystic duct and duct of Lushka. Type B denotes occlusion of a part of the biliary tree, almost invariably the aberrant right sectoral hepatic duct. Type C represents transaction without ligation of the right sectoral hepatic duct and Type D a lateral injury to an extrahepatic bile duct, potentially requiring a major reconstruction
Slide 34 : Strasberg classification of laparoscopic injuries to the biliary tract Type A injuries originate from small bile ducts that are entered in the liver bed or from the cystic duct. Type B (and Type C )injuries are most always involved aberrant right hepatic duct.. Type B ( type E) injuries occlude the biliary tree and bilomas do not occur.
Slide 35 : Strasberg Type A & B
Slide 36 : Strasberg type C & D Type C represents transaction without ligation of the right sectoral hepatic duct and Type D a lateral injury to an extrahepatic bile duct, potentially requiring a major reconstruction
Slide 37 : Type E of Strsaberg classification Type E. The latter, representing biliary strictures, has been further subdivided as per Bismuth's classification into E1 to E5.
Slide 38 : Strsaberg subtype E
Slide 39 : Bismuth classification of benign bile duct strictures based on the location of the lesion in relation to the hepatic duct bifurcation. Bismuth classification Type 1 to Type5
Slide 40 : Bismuth[18] classified biliary strictures into five types Type 1: Stricture >2 cm from the confluence of the hepatic ducts.Type 2: Stricture <2 cm from the confluence with remnant of the CHD.Type 3: Stricture flush with the confluence with the confluence intact.Type 4: Stricture involves the confluence.Type 5: Stricture involving an aberrant right sectoral hepatic duct, with or without a concomitant CHD stricture.A review of 74 patients[17] at the Vanderbilt University Medical Center, Nashville, referred with bile duct injuries sustained during LC suggested that they are frequently severe and related to cautery and high clip ligation and the level of injury was almost evenly divided between Bismuth Type 3, 4 and 5 versus Bismuth Type 1 and 2.[
Slide 41 : Bismuth classification Does not stipulate the length of the injury . This information is useful for non operative treatment such as percutaneus or endoscopic technique which may be used when injury is stenosis. Sometimes even clip occlusion is treated non surgically
Slide 42 : Bismuth classification(modified)
Slide 43 : Drawback of bismuth The generally accepted classification of Bismuth for bile duct lesions used in many previous reports of strictures after open surgery is a classification according to the level of injury but unfortunately not to the nature of the lesion and can therefore not be used for all lesions (bile leaks) after laparoscopic surgery. Several new classifications for a bile duct injury have been reported during the past years. McMahon suggested in a review a more simplified definition by dividing BDI only into major and minor bile duct injury (ref 5 ).
Slide 44 : Mcmohan classification(1993) In 1993 Mcmohan introduced a new classification for bile duct injuries reported (ref 12 ). In this new classification a bile duct injury was defined as any clinically evident damage to the biliary system including the cystic duct and intrahepatic duct radials ( so called duct of Luschka ).
Slide 45 : Four types of bile duct injury can be identified: (Mcmohan) A. Cystic duct leaks or leakage from aberrant or peripheral hepatic radicles.B. Major bile duct leaks with or without concomitant biliary strictures.C. Bile duct strictures without bile leakage.D. Complete transection of the bile duct with or without excision of a part of the bile duct. . It was found that treatment and prognosis of a bile duct injury are mainly dependent on the nature of the lesion.
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Slide 48 : Consequences of Injury-EARLY OR LATE if BDI  are unrecognized  or managed  improperly, life-threatening complications like Biliary cirrhosis,  Portal hypertension, Recurrent cholangitis, may develop DEATH can ensue….
Slide 49 : Recognition-Diagnosis delay Delayed diagnosis make the treatment more difficult and is responsible of a more complex course: Transection of the major bile duct causes bile leakage and may present with external biliary fistula (if a biliary drainage was left in place) or with acute abdomen (choleperitoneum); A complete ligation of major bile duct presents with post-operative obstructive jaundice.
Slide 50 : TREATMENT OPTIONS A number of alternatives exist Percutaneous transhepatic STENTING Endoscopic stenting procedure, Surgery repair) for elective repair of bile duct lesions, But the best treatment remains still under discussion.
Slide 51 : Diagnosis& Clinical presentation The time interval between laparoscopic cholecystectomy and the detection of the lesion varies widely . Three different groups of patients with a bile duct injury can be identified. 1. DURING OR:Firstly the injury can be detected during the laparoscopic procedure. In a previous study from the Netherlands about 1/3 of the lesions were detected during the initial surgical procedure which is in accordance with the literature ( 8 ). Detection of an injury during the procedure was not dependent on the general use of routine cholangiography. Nowadays most lesions should be detected during the procedure because of the wide attention and many articles about this subject.
Slide 52 : Diagnosis & cl presentations-delayed identification A second group of patients are those with a delayed identification ( > 24 hours after surgery ) of a bile duct injury. These patients presented postoperatively with a median interval after surgery of 7 days. In one of the series symptoms in the early postoperative phase were aspecific as general malaise, nausea, vomiting, anorexia, abdominal pain and low grade fever and these aspecific symptoms were probably responsible for the delay in diagnosis. These patients were frequently discharged from hospital the second postoperative day and are re - admitted after a few days because of persistent complaints. Other symptoms may become manifest later and consist of sepsis and jaundice and in most patients these symptoms will eventually lead to the (delayed) detection of the injury
Slide 53 : Diagnosis & Cl presentaion…contd A third group consists of patients have a relatively long symptom free interval ( even up to more than one year ) Present with obstructive jaundice frequently without cholangitis due to a stricture. It is suggested that these late bile duct strictures originate mainly from ischaemic lesions caused by extensive dissection, or partial occlusion of the common duct with a clip during the initial procedure
Slide 54 : PREDISPOSING FACTORS & PRECAUTIONS A number of predisposing factors have been associated with bile duct injury during cholecystectomy Acute cholecystitis, Congenital anomalies of the bile ducts, Intra-operative bleeding from the cystic artery or hepatic artery and finally, failure to identify the structures of the triangle of Calot. Panic clips or sutures in case of bleeding Injudicious use of cautery around calot triangle
Slide 55 : PREVENTION BETTER THAN CURE-ADHERE TO BASIC RULES The majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized If the surgeon adheres to a simple and basic rule of biliary surgery No structure is ligated or divided until it is clearly identified. The proper use of intra-operative cholangiography may identify an impendig injury before the level of injury is extended: Early recognition with an immediate conversion to an open procedure and prompt repair can result in a significant decreased morbidity, mortality, length of hospitalization and cost saving unfortunately injury is recognized during the laparoscopic procedure only in about 30 % of the cases.Low threshold for conversion or seeking help.
Slide 56 : Treatment NeedsTeam work The combined effort of surgeons, endoscopists and radiologists is necessary to optimize the management of patients with laparoscopic cholecystectomy-related biliary complications, so according to us a multi-specialized approach is mandatory for the treatment of more complex iatrogenic biliary lesions. The complexity of these clinical situations and the possibility of severe consequences need that these patients should treated in highly specialized Centers
Slide 57 : Diagnostic procedures-steps An early diagnosis is important and can easily be established by Ultrasound, and is extremely helpful in the detection of a fluid collection or bile duct dilatation. Subsequent percutaneous aspiration of bile will establish the diagnosis. Unfortunately a fluid collection ( suggesting a bile duct lesion ) was still an indication for exploratory laparotomy for many surgeons. Laparotomy should however be avoided in this stage without a classification of the injury and a clean therapeutic strategy. The next step is an ERCP not only to establish the diagnosis but in particular to identify the nature and level of the lesion Basic work up- LFT;USG(Collection?dilation of biliary tree: MRCP;ERCP and ?or stenting;PTC;laparoscopy
Slide 58 : TreatmentPlanning The multidisciplinary approach is not only advocated for the diagnostic work-up ( classification ) but is also important to select patients for different treatment modalities. Furthermore one should realize that not all forms of treatment are available in every hospital. Therefore treatment principles as outlined in the next slide are only useful and applicable in centers with sufficient experience in interventional radiology, therapeutic endoscopy and reconstructive surgery. Unfortunately bile duct injuries will occur in every hospital and can not totally be prevented. Inadequate diagnostic work up and subsequent suboptimal treatment of these injuries is however not acceptable nowadays after many experienced centers showed excellent results of repair procedures.
Slide 59 : Guidelines &Treatment policy is Totally different for acute injuries detected during surgery compared with delayed detected injuries. If an injury is detected during the laparoscopic procedure one should first call for help and consult a surgeon with sufficient experience. Next, further laparoscopic or open exploration should be performed to identify the structures in the hepatoduodenal ligament and identify the severity of the injury. If local anatomy is still unclear one should stop further exploration and only perform adequate drainage. If the bile duct lesion is adequately identified and not associated with extension damage of part of the bile duct and therefore suitable for a primary repair an end - to - end anastomosis should be performed with drainage by a T - tube. This procedure is associated with a high incidence of development of late bile duct strictures but one should realize that this procedure provides an optimal biliary drainage with a reasonable chance for cure and otherwise creates the optimal circumstances for reconstructive surgery by means of an elective hepaticojejunostomy at a later stage
Slide 60 : Treatment policy…contd If part of the bile duct is accidentally resected but the proximal border is well below the bifurcation of the hepatic duet and optimal local circumstances ( experience ) are available an acute reconstruction by a hepatico-jejunostomy can be performed. For higher lesions at the bifurcation or intrahepatically located lesions without a dilated ductal system adequate drainage seems to be indicated and patients should be referred for elective reconstruction later.
Slide 61 : Treatment policy-gold standard If local experience is limited during detection of the injury in this acute phase one should limit exploration and only perform a drainage procedure and refer the patient to an experienced center.
Slide 62 : Major injuries- if late detection Patients with a liver duct injury that has been detected in a later phase, Should never undergo exploration before classification of the injury except patients suffering from severe biliary peritonitis which cannot be managed by percutaneous biliary drainage. Drainage should preferably be performed by ERCP and stent insertion or PTC combined with adequate percutaneous drainage of a fluid collection. An important factor for the final outcome of the surgical treatment is the timing of surgery. It is reported that a surgical reconstruction by a hepaticojejunostomy in the "late" acute postoperative phase ( often in a patient with bile leakage and subsequent peritonitis, ileus and the presence of local inflammatory changes in the hepatoduodenal ligament ) is associated with a higher risk for postoperative complications such as bile leakage and eventually stenosis of the anastomosis. Therefore patients are sent home with a drainage catheter and occasionally some of these patients will have a nasogastric tube to replace bile into the duodenum
Slide 63 : Timing of Reconstruction Reconstruction is performed electively after 6 to 8 weeks. Patients with an acute reconstruction in non optimal circumstances have a high incidence ( 50 % ) of stenosis of the anastomosis instead of 90 % success rate after elective reconstruction.
Slide 64 : Summary Results from many recent series most patients ( 94 % ) with a Type A lesion(Mcmohan series) could be treated with an endoprothesis. Patients with Type B lesions were successfully treated endoscopically in 70 % and with a Type C lesions 50 %. All patients with Type D lesions underwent surgical reconstruction by one or more intrahepatic hepatojejunostomies. Patients who develop a stenosis after a surgical reconstruction are preferably treated by percutaneous transhepatic pneumodilatation
Slide 65 : Prevention tips A thorough knowledge of the anatomy of the region including the possible anomalies is important in preventing iatrogenic bile duct injuries. Both open and LC are based on similar operative principals. Proper exposure and visualization, Careful dissection, adequate hemostasis, careful placement of ligatures and clips. Division of structures after proper identification are the essence of safe cholecystectomy
Slide 66 : Laparoscopic cholecystectomy Lawrence et al[12] stressed on focused training to heighten vigilance against visual perception illusion and error of judgement as they showed that there are only a few points within LC where complication-causing errors occur like mistaking the CBD to be the CD or dissection too close to the CHD. The early prediction that the rate of bile duct injury during LC would decline substantially with increased experience has not been fulfilled Since the injuries occurring at LC are frequently more severe and extend to a higher level than in open cholecystectomy (Strasberg E3 to E5 injuries occur in 31% of LC against 12% of open cholecystectomy) prevention should always be the aim.[20] :
Slide 67 : Tips for preventing iatrogenic bile duct injuries(Asbun et al) Maximum cephalic fundal traction for better visualization of the Calot's triangle.• Lateral and inferior traction on the Hartman's pouch opens up the angle between the CD and the CHD and avoids their alignment [Figure - 1]b.• Calot's triangle must be freed of fatty and areolar tissue.• Dissection to be started near the neck of the gall bladder (cystic lymph node is an important land mark) and then proceed from the lateral to the medial direction, keeping close to the gall bladder. • Freeing the posterolateral attachments of the gall bladder to the liver creates a good window and the junction of the neck of the gall bladder and the CD is defined all round. Visual identification of the CBD is not essential or recommended.• A 30o telescope is preferable as it can be turned to achieve an en face view of the Calot's triangle. Withdrawing the telescope intermittently gives the surgeon an overall perspective and spatial orientation.• Clips are to be placed close to the gall bladder after proper visualization of both their limbs. A short or wide CD should preferably be tied.
Slide 68 : Tips…contg • Excessive and unnecessary dissection or use of electrocautery near the CBD to be avoided. Cautery to be used at very low power setting in Calot's triangle.[21]• Electrocautery on tissues close to metal clips concentrates thermal energy and desiccates the tissue making the clips less secure predisposing to bleeding and biliary fistula and hence should always be avoided.• Any bleeding should be controlled only after accurate identification of its source and the neighbouring structures.• Dissection should be close to the gall bladder while it is separated from the liver bed.• Always better to seek the opinion of senior colleagues of the same institution if one feels "lost"; if doubt persists convert to open cholecystectomy-it only shows good judgement.
Slide 69 : Tips during Open cholecystectomy Adequate incision, good retraction and able assistance help in proper exposure and visualization and are prerequisites for safe cholecystectomy.• Proper identification of the structures of the Calot's triangle before any structure is ligated or divided. It is important to remain close to the gall bladder during dissection to avoid injury to the RHD or one of its anomalies.• If the anatomy is not clear a cholecystostomy or partial cholecystectomy is preferable.• In cirrhosis, excessive bleeding during separation of the gall bladder may be reduced by leaving the posterior wall of the gall bladder denuded of its mucosa, attached to the liver bed.• When haemorrhage obscures the anatomy one should refrain from using clamps blindly. Instead, Pringle manoeuvre helps in better visualization and accurate placement of clips and clamps.
Slide 70 : Caution Both antegrade and retrograde cholecystectomy may be associated with CBD injury and thus neither should give a false sense of security to the operating surgeon.
Slide 71 : In conclusion Laparoscopic cholecystectomy has shown its overall safety and most centers are now well beyond the learning curve. The incidence of bile duct injury seems to be marginally increased compared with open surgery and a decrease of the incidence of injuries has been reported recently. Management in terms of early diagnosis and classification of injuries before explorative laparotomies is still suboptimal and in our series no difference could be found between 1990 - 1994 and 1995 - 1996. Still 30 % of the patients with a bile duct injury underwent a diagnostic laparotomy. Most Type A and B injuries ( 90 % ) can be treated endoscopically and all Type D lesions have to be treated by surgical reconstruction. A delayed elective reconstruction was associated with less complications compared to acute repair under suboptimal circumstances.
Slide 72 : Last but not least Bile duct injuries are rare complications of both open and LC. They can devastate an individual by turning him into a "biliary cripple" and most ultimately die of hepatic failure. They often result from errors of human judgement and are thus preventable. A marriage of the experiences gained from open cholecystectomy and the advantages of LC in terms of visualization and magnification will help in reducing the incidence of such catastrophes.
Slide 73 : References 1. Gouma, D.J., Obertop, H.: Gallstone treatment in "the laparoscopic cholecystectomy era". Neth. J. Med., 45, 1994: 1 - 72. Go, P.M.N.Y.H., Schol, F.P.G., Gouma, D.J.: Laparoscopic cholecystectomy in the Netherlands. Br. J. Surg., 80, 1993: 1180 - 11833. Deriel, D.J., Millikan, K.W., Exonomou, S.G. et al.: Complications of laparoscopic cholecystectomy: a national survey of 4.292 hospitals and an analysis of 77.604 cases. Am. J. Surg., 165, 1993: 9 - 144. Lee, V.S., Chari, R.S., Cucchiaro, G. et al.: Complications of laparoscopic cholecystectomy. Am. J. Surg., 165, 1993: 527 - 5325. McMahon, A.J., Fullarton, G., Baxler, J.N. et al.: Bile duct injury and bile leakage in laparoscopic cholecvsteetomy. Br. J. Surg., 82, 1995: 307 - 3136. Schol, F.P.G., Go, P.M.N.Y.H., Gouma, D.J.: Risk factors for bile duct injury in laparoscopic cholecystectomy: analysis of 49 cases. Br. J. Surg., 81, 1994: 1786 - 17887. Rossi, R.L., Schirmer, W.J., Braasch, J.W. et al.: Laparoscopic bile duct injuries. Risk factors, recognition, and repair. Arch. Surg., 127, 1992: 596 - 6028. Gouma, D.J., Go, P.M.N.Y.H.: Bile duct injury during laparoscopic and conventional cholecystectomy. J. Am. Coll. Surg., 178, 1994: 229 - 2339. Peters, J.H., Gibbons, G.D., Innes, J.T. et al.: Complications of laparoscopic cholecystectomy. Surgery 110, 1991: 769 - 77810. Richardson, M.C., Bell, G.: Fullarton GM and the West of Scotland laparoscopic cholecystectomy audit group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy an audit of 5913 cases. Br. J. Surg., 83, 1996: 1356 - 1360 11. Nair, R.G., Dunn, D.C., Fowler, S. et al.: Progress with cholecystectomy: improving results in England and Wales. Br. J. Surg., 84, 1997: 1396 - 139812. Bergman, J.J.G.H.M., Brink van den G.R., Rauws, E.A.J. et al.: Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 38, 1996: 141 - 14713. Keulemans, Y.C.A., Bergman, J.J.G.H.M., Wit de L.T. et al.: Improvement in the management of bile duct injuries ? In press: J. Am. Coll. Surg., 199814. Schipper, I.B., Rauws, E.A.J., Gouma, D.J. et al.: Diagnosis of right hepatic duct injury after cholecystectomy: the use of cholangiography through percutaneous drainage catheters. Castrointest. Endosc., 44, 1996: 35l - 35415. Lillemoe, K.D., Martin, S.A., Cameron, J.L. et al.: Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management. Ann. Surg., 225, 1997: 459 - 47116. Mirza, D.F., Narsimhan, K.L., Ferraz Neto B.H. et al.: Bile duct injury following laparoscopic cholecystectomy: referral pattern and management. Br. J. Surg., 84, 1997: 786 - 79017. Moossa, A.R., Easter, D.W., Van Sonnenberg E. et al.: Laparoscopic injuries to the bile duct. Ann. Surg., 215, 1992: 203 - 20818. Branum, G., Schmitt, C., Baillie, J. et al.: Management of major biliary complications after laparoscopic cholecystectomy. Ann. Surg., 5, 1993: 532 - 541.

 


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