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 25 February 2018

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News

Technique errors in laparoscopic cholecystectomy may cause bile duct injuries

There may be fundamental errors in the technique of laparoscopic cholecystectomy, as a significant proportion of bile duct injuries are not related to surgical inexperience, according to research published in the October issue of the Annals of Surgery.

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Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%.

These injuries were most commonly reported early in each surgeon's experience. However, it was not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern.

A team from the USA has therefore examined this.

The study assessed whether surgical residency training has an influence on the occurrence of common bile duct injuries during laparoscopic cholecystectomy.

The research team also assessed the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency, as opposed to surgeons trained in laparoscopic cholecystectomy during residency.

An anonymous questionnaire was circulated to 3657 surgeons across the United States, who had completed an Accreditation Council for Graduate Medical Education (ACGME) approved residency, between 1980 and 1990 (Group A) or between 1992 and 1998 (Group B).

All surgeons in Group A learned laparoscopic cholecystectomy after residency, while all those in Group B studied laparoscopic cholecystectomy during residency.

Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laproscopic cholecystectomy in the surgeon's hospital.

In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment.

The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

A total of 45% (n = 1661) of the questionnaires were completed and returned.

Laparoscopic cholecystectomies - surgeons' techniques may be flawed.
Annals of Surgery

Mean practice experience was 13.6 years for Group A and 5.4 years for Group B.

At least one injury occurrence was reported by 422 surgeons (38%) in Group A, and 143 surgeons (27%) in Group B.

A total of 40% of the injuries in Group A occurred during the first 50 cases, compared with 22% in Group B.

These results compared with values of 30% and 33% for Groups A and B, respectively, for surgeons who had performed more than 200 laparoscopic cholecystectomies.

Independent of the number of laparoscopic cholecystectomies completed since residency, Group A surgeons were 39% more likely to report one or more biliary injuries than their counterparts in Group B. They were also 58% more likely to report two or more such injuries.

Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (81% vs 45%).

Of those major bile duct injuries that did occur, 64% required biliary duct reconstruction. Most injuries were definitively treated at the hospital where the injury occurred - only 15% required referral to another center for repair.

Accepting that the survey underestimates the true frequency of bile duct injuries, the authors conclude that residency training decreases the likelihood of injuring a bile duct. However, it does so only by decreasing the frequency of early "learning curve" injuries.

Dr Stephen Archer, of Emory University, Atlanta, Georgia, concluded, "If one accepts a liberal definition of the learning curve (200 cases), then it appears that at least one third of injuries are not related to inexperience. They may reflect fundamental errors in the technique of laparoscopic cholecystectomy, as practiced by a broad population of surgeons in the United States."

Ann Surg 2001: 234 (4): 549-59
01 October 2001

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