From the Guidelines
The rate of common bile duct (CBD) injuries during laparoscopic cholecystectomy ranges from 0.4% to 1.5%, with major bile duct injuries occurring in approximately 0.1-0.5% of cases, as reported by the World Society of Emergency Surgery (WSES) in 2021 1.
Background
Laparoscopic cholecystectomy (LC) is a common procedure for gallstone disease, and CBD injuries are a significant complication, with a higher incidence in LC compared to open cholecystectomy.
Risk Factors and Prevention
The risk factors for CBD injuries include severe inflammation, aberrant anatomy, surgeon inexperience, and technical errors during dissection. The critical view of safety technique, recommended by SAGES, has been shown to reduce injury rates when properly implemented 1.
Diagnosis and Management
Early recognition of CBD injuries is crucial, as delayed diagnosis beyond 24-48 hours significantly worsens outcomes. Treatment approaches vary based on injury severity, ranging from endoscopic management with stenting for minor leaks to complex biliary reconstruction (typically Roux-en-Y hepaticojejunostomy) for major transections 1.
Long-term Complications
Long-term complications following CBD injuries include strictures, recurrent cholangitis, and secondary biliary cirrhosis in approximately 10-30% of cases, highlighting the importance of prevention through proper surgical technique and training 1.
Key Recommendations
- Prompt recognition and management of CBD injuries are essential to prevent long-term complications 1.
- The critical view of safety technique should be implemented to reduce injury rates 1.
- Early referral to a specialist center can significantly decrease the rate of postoperative complications 1.
From the Research
Common Bile Duct Injuries and Complications
- The rates of common bile duct (CBD) injuries and complications from laparoscopic cholecystectomy have been reported in various studies 2, 3, 4, 5, 6.
- According to a study published in 1992, the major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%) 2.
- A study published in 2017 reported that the incidence of bile duct injury during laparoscopic cholecystectomy fails to fall below 0.3%-0.6% 3.
- Another study published in 2009 analyzed the factors contributing to a record of zero CBD injuries in 10,000 consecutive laparoscopic cholecystectomies and reported a duct leak rate of 0.16% 4.
- The incidence of CBD injuries has been reported to be 0.29% in a retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies 5.
- A retrospective population-based cohort study published in 2001 reported a rate of CBD injury in patients undergoing LC of 2.5/1000 operations 6.
Prevention and Management of CBD Injuries
- The use of intraoperative cholangiography (IOC) has been associated with a decreased rate of major CBD injury during LC 6.
- Surgeon experience and the use of IOC are independent predictors of injury 6.
- A special classification for bile duct injuries has been developed to define the types of injury, their occurrence, and frequency, and their management by endoscopic and surgical techniques 5.
- Endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents, have been used to manage CBD injuries with excellent to good results in 76% of cases up to 3 years of follow-up 5.
Rates of CBD Injuries and Complications
- The rates of CBD injuries and complications from laparoscopic cholecystectomy reported in the studies are: