From the Guidelines
The answer is C. Disclosing error. When you inform a patient post-operatively that you injured the common bile duct (CBD) during a laparoscopic cholecystectomy, you are disclosing a medical error. This represents an unintended injury to a structure that should have been preserved during the procedure. CBD injury is a recognized complication of laparoscopic cholecystectomy, occurring in approximately 0.4-1.5% of cases, but it is considered a preventable adverse event resulting from technical error rather than an unavoidable risk 1.
Key Considerations
- Proper disclosure involves explaining what happened, the potential consequences (such as bile leakage, stricture formation, or need for additional procedures), and the plan for management.
- This differs from disclosing a complication, which would refer to an inherent risk of the procedure that occurred despite proper technique.
- Ethical practice and patient autonomy require transparent communication about errors, which builds trust and allows patients to make informed decisions about their subsequent care.
- The management of bile duct injuries is complex and requires prompt identification and management, with a wide spectrum of interventions available, including computed tomography (CT)-guided drainage, endoscopic, and surgical techniques 1.
Management and Outcomes
- The treatment of BDIs is generally considered successful, with an overall success rate of 83.3% in the early period, but late postoperative complications, such as stricture and cholangitis, can occur in up to 32.3% of patients 1.
- The incidence of anastomotic strictures after Roux-en-Y hepaticojejunostomy varies between 4.1% and 69%, with a median time to stricture formation of 11-30 months 1.
- BDI-related mortality varies between 1.8% and 4.6%, with some evidence suggesting that associated vascular injury, level of BDI, sepsis or peritonitis, and postoperative bile leakage are associated with worse outcomes 1.
Guidelines and Recommendations
- The 2020 WSES guidelines provide evidence-based recommendations for the detection and management of BDIs during cholecystectomy, covering key aspects such as strategies to minimize the risk of BDI, classification and staging of BDI, and management of intraoperatively and postoperatively detected BDI 1.
- The guidelines aim to facilitate efficient interdisciplinary cooperation and standardize the detection and management of BDIs, with the goal of improving patient outcomes and reducing morbidity and mortality.
From the Research
Definition of Terms
- Disclosing an apparent complication: Informing the patient about a potential issue that may have arisen during the procedure.
- Disclosing complication: Notifying the patient about a confirmed complication that has occurred.
- Disclosing error: Informing the patient about a mistake that was made during the procedure.
- Disclosing an apparent error: Notifying the patient about a potential mistake that may have been made.
Analysis of the Situation
During a laparoscopic cholecystectomy (lap. chole), if the common bile duct (CBD) is injured, it is essential to inform the patient post-operatively. This situation can be considered as:
- Disclosing a complication, as the injury to the CBD is a confirmed issue that has occurred during the procedure 2, 3, 4.
- Disclosing an error, as the injury to the CBD may be a result of a mistake made during the procedure, such as misidentification of the biliary tract anatomy 5, 4.
Key Points to Consider
- The most common cause of bile duct injuries during laparoscopic cholecystectomy is the failure to recognize the anatomy of the triangle of Calot 2, 4.
- Prompt radiographic visualization of the biliary tract is indicated in patients who have pain, jaundice, and bile collections postoperatively 3.
- A hepaticojejunostomy is the procedure of choice for repair of bile duct injuries 3, 4.
- Early recognition and adequate multidisciplinary approach is the cornerstone for the optimal final outcome 5.