Ask how to identify iatrogenic bile duct injury

Cholelithotomy: There is no such surgical method at the moment, I think you might mean laparoscopic cholecystectomy. Because if the gallbladder is cut open to remove the stones, this surgical method is not complicated, but after a hundred years of practice, this surgical method has long been abandoned in the long river of history.

Because gallstones are a manifestation of gallbladder inflammation, the chronic inflammation of the gallbladder cannot be eliminated by simply removing the stones, so the first rate of gallstones is reported to be more than 60%-80% within half a year.

There are indeed two possibilities for the situation you described:1As described by the surgeon, it is mirizzi syndrome, in which gallstones in the neck of the gallbladder become incarcerated, compressing the common bile duct, leading to the ulceration of the common bile duct and even the formation of a common bile duct-gallbladder fistula.

2.Just as you suspected: loss of bile ducts during laparoscopic surgery, forced bile duct-jejunostomy.

In either case, because the bile duct is not dilated, the difficulty of biliary-intestinal anastomosis is quite high, and the long operation time does not explain the problem.

To identify the above two conditions, it is necessary to:1Preoperative imaging examination, the size of the stone, whether there is incarceration, etc., whether there is a possibility of mirizzi syndrome; 2.

The intraoperative exploration recorded by the surgeon in the surgical record and the bile duct-jejunostomosis pattern can also be inferred; 3.The shape and size of the stones removed from the book.

Recommendation: If your suspicion is very likely, it is recommended that you seal the case and request a medical malpractice evaluation, as laparoscopic biliary loss falls under the category of medical malpractice.

1 Iatrogenic bile duct injury J identification and its difficulty, it is impossible to identify at all, many after laparotomy only to find that the bile duct inflammation is severe suppuration and rupture.

2 The bile duct is stuck with a stone, which is very painful in the early stage, and if the local bile duct is stuck for a long time, it will be ischemic necrosis, or even suppuration, and the pain may be relieved.

3 If the operation goes well, the total time is about 4---6 hours.

Gallstone preservation, may refer to the gallbladder-sparing surgery, upstairs said a little vague, at the beginning of the proposed surgery, biliary-intestinal anastomosis is generally about 3-5 hours.

Don't worry, this surgery will be about 5 hours, and the pain is still painful.

This can be very large, and the doctor will also explain this possibility to the patient's family before the surgery. Some conditions cannot be detected by examination, such as biliary tract malformations, bile duct strictures, infected and ulcerated bile ducts, multiple stones or abnormal stone shapes, etc. Biliary jejunostomy is highly technical and difficult, and it is possible to spend several hours.

This entry was written by Zhang Wenxing (Chief Physician), Department of General Surgery, First Affiliated Hospital of Hunan University of Traditional Chinese Medicine, Iatrogenic bile duct injury refers to the accidental injury of the bile ducts during abdominal surgery, usually the injury of the extrahepatic bile ducts. It is mainly seen in biliary manual slag surgery, especially cholecystectomy, but can also occur during gastrectomy, liver rupture repair, and liver resection.

In addition, endoscopic sphincterotomy, EST has also been associated with bile duct injury.

1.Anatomical factors.

Gallbladder triangular variations are very common, mainly the appearance of the right parahepatic duct, and the abnormality of the junction site between the cystic duct and the extrahepatic bile duct. Incarcerated stones add to the complexity of the anatomy. In addition to bile duct variations, there are branching abnormalities in the hepatic artery and portal vein.

Confusion during surgery can easily lead to hemorrhage, and dissection of the gallbladder triangle in a pool of blood can easily cause bile duct injury. Therefore, familiarity with bile duct variants is key to the success of the procedure.

2.Pathological factors.

For example, in the case of acute purulent cholangitis, gangrenous cholecystitis, chronic atrophic cholecystitis, and mirizzi syndrome, edema, hyperemia, inflammation, and internal fistula of the gallbladder and surrounding tissues make it difficult to identify the normal anatomical relationship and increase the difficulty of surgery. At the same time, it also increases the possibility of accidents. In addition, chronic duodenal ulcer may damage the bile duct and even the portal vein during gastrectomy due to inflammation and adhesion of the surrounding tissues, anatomical variation of the hepatoduodenum and shortening the distance between the bile duct and the ulcer.

3.Technical factors.

The experience of the surgeon and the seriousness of the surgeon are important factors in the success of cholecystectomy. In addition, intraoperative anesthesia, intraoperative lighting, exposure, and whether the patient is obese or not are all factors that affect the success of the operation. In addition to the above reasons, the technical condition of the laparoscopic instrument itself is also a potential risk factor for bile duct injury during LC.

First of all, the surgeon is affected by the lack of clarity of the image and field of vision of the two-dimensional camera system. Secondly, the surgical operation is only completed by instruments, and cannot be touched by hands, which lacks experience. In addition, when the light source and lens pull the gallbladder to the right cephalad, the neck of the gallbladder will block the calot triangle, making the angle between the cystic duct and the common bile duct smaller, and it is easy to mistake the common bile duct for the cystic duct and ligation.

It is more likely to occur when the cystic duct is thick or short or parallel to the common bile duct. In addition, delayed high bile duct stenosis after LC surgery is also common, which is related to the electrothermal injury of extrahepatic bile ducts caused by the use of electrosurgical and electrocoagulation.

The case fatality rate for biliary tract injury is about 5%, and it is common in people with disabilities. If the damage cannot be repaired, episodic cholangitis and secondary liver disease are inevitable. The success rate of surgical correction of stenosis is 90%.

In some of the most stenotic centers, their experience suggests that patients who have not been relieved of obstruction after multiple previous experiences can also achieve better results. Therefore, liver transplantation is not a consideration for these conditions**.