What is the risk of significant blood loss during laparoscopic cholecystectomy with intraoperative cholangiogram?

From the Guidelines

The risk of significant blood loss during laparoscopic cholecystectomy with intraoperative cholangiogram is moderate, with an estimated incidence of bile duct injuries ranging from 0.4-1.5% of cases, and requires close monitoring and possibly blood transfusion. This amount of blood loss is higher than the typical expected during an uncomplicated laparoscopic cholecystectomy. The patient should be monitored for signs of hypovolemia including hypotension, tachycardia, decreased urine output, and altered mental status. Laboratory tests including complete blood count, coagulation studies, and electrolytes should be obtained postoperatively. If the patient shows signs of hemodynamic instability or significant anemia (hemoglobin <7-8 g/dL), blood transfusion may be necessary. Intravenous fluid resuscitation with crystalloids (such as normal saline or lactated Ringer's) should be initiated at 1-2 times the maintenance rate until the patient is hemodynamically stable. The increased blood loss may indicate a surgical complication such as injury to blood vessels, liver parenchyma, or difficulty with the dissection, which could be associated with higher risk of bile duct injury or postoperative bleeding, as reported in the 2020 WSES guidelines for the diagnosis and treatment of acute calculus cholecystitis 1.

Some key points to consider in the management of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiogram include:

• The safety of laparoscopic cholecystectomy in acute calculus cholecystitis has been confirmed by several studies, including a systematic review comparing open versus laparoscopic cholecystectomy, which showed a lower complication rate and shorter hospital stay with the laparoscopic approach 1.
• The incidence of bile duct injuries during laparoscopic cholecystectomy is estimated to be between 0.4-1.5% of cases, with most injuries recognized either during the procedure or in the immediate postoperative period, as reported in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1.
• The management of bile duct injuries requires prompt identification and treatment, with a variety of interventions available, including computed tomography (CT)-guided drainage, endoscopic and surgical techniques, and close cooperation between gastroenterologists, radiologists, and surgeons, as recommended in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1.

Therefore, the patient requires vigilant postoperative monitoring for continued bleeding, bile leak, or signs of infection, and the surgical team should be prepared to manage any potential complications that may arise, as reported in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1 and the 2020 WSES guidelines for the diagnosis and treatment of acute calculus cholecystitis 1.

From the Research

Risk of Significant Blood Loss

• The risk of significant blood loss during laparoscopic cholecystectomy with intraoperative cholangiogram is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies discuss the safety and efficacy of intraoperative cholangiography during laparoscopic cholecystectomy, with no mention of significant blood loss as a complication 3, 4, 6.
• One study notes that all 9 intraoperative injuries during laparoscopic cholecystectomy were successfully managed by laparoscopic procedures, with no open conversion required, but does not specify the nature of these injuries 2.
• Another study reports no operative complications related to intraoperative cholangiography 3.
• A study comparing routine LC treatment to LC+IOC treatment found no significant differences in complication rates, including no cases of fatal complications in either group 6.

Intraoperative Cholangiography Complications

• The provided studies suggest that intraoperative cholangiography is a safe procedure with no significant complications reported 3, 4, 6.
• One study notes that IOC added an average of 28 minutes to total theatre time, but did not report any complications related to the procedure 3.
• Another study found that IOC lengthened operative time, but did not improve rates of CBD stone retainment or bile duct injury 6.

Laparoscopic Cholecystectomy Complications

• The studies discuss the complications of laparoscopic cholecystectomy, including bile duct injury, but do not specifically address the risk of significant blood loss 2, 5.
• One study notes that the most common major complication of laparoscopic cholecystectomy is bile duct injury, which can have catastrophic repercussions for patients 5.
• Another study reports that most complications encountered during laparoscopic cholecystectomy can be managed laparoscopically 2.