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Complications of Laparoscopic Surgery

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Nilo de los Santos

on 17 September 2012

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Transcript of Complications of Laparoscopic Surgery

Common bile duct injury Bile leak Complications of Laparoscopic Cholecystectomy

Nilo C. de los Santos, M.D.
FPCS, FPSGS

DLS-STI MEDICAL CENTER Bile leak after LC: Stent vs No stent Bile leak after LC: How long a stent? Bile leak after LC: Prophylactic
use of drains at LC Evaluation of patient after LC
When to suspect a problem?
Majority of patients are discharged within 24 hours of surgery
Should look well after laparoscopic surgery
Unresolved or persistent abdominal complaints or evidence of
infection warrant a focused history and physical
Especially examine RLQ
Ultrasound, CXR for free air Early Complication:
Bile leak
Common bile duct injury
Hemorrhage
Injury to viscera
Retained stones and abscess formation
Late Complication:
Biliary strictures
Cystic duct clip stones Complications of Laparoscopic Cholecystectomy
Snap interpretation will be wrong if there is:
Eye ball degradation
Lack of initial identification and memory of key
structure to the point of absolute certainty.

Most important technical error is hilar bleeding and
frantic atempts are made to control bleeding by
electrosurgery. Bile leak N = 90 patients presented with bile leaks after cholecystectomy (open
and LC)
33% had a CBD stone
53% leaks came from the cystic duct
1 had ascaris in the common bile duct... Bile leak after LC: ERCP Agarwal et al Hepatobiliary & Pancreatic Dis International 2006. HIDA scan: nuclear activity in the subhepatic area, right paracolic gutter, or diffusely in the peritoneal cavity
The sensitivity of HIDA: as high as 70% (especially with late pictures
Diagnosis: ERCP defines the site (non dilated IHBDs are difficult to cannulate at PTC) Bile leak after LC: Diagnosis Massoumi et al J Clin Gastroenterology 2007
Mergener et al. Gastrointest Endosc 1999 Bile leak, a complication of any cholecystectomy
LC: 0.5 to 3%
OC: 0.1 to 0.5%
The severity of leaks seems to be greater after LC Bile leak after LC Massoumi et al J Clin Gastroenterology 2007
Massoumi et al Gastrointestinal Endosc 1999 Bile leak, a complication of any cholecystectomy
After LC: 0.5 to 3%
After OC: 0.1 to 0.5%
The severity of leaks seems to be greater after LC. Bile leak after LC Massoumi et al. J Clin Gastroenterology. 2007
Mergener et al. Gastrointestinal Endosc. 1999 Massoumi et al J Clin Gastroenterology 2007
Mergener et al Gastrointest Endosc 1999 Bile leak after LC Most common location for biloma is the subhepatic area
Ultrasound: small fluid collection in the gallbladder fossa in 10% to
28% of postoperative patients
Large size collection: danger... Most common location for biloma is the subhepatic area
Ultrasound: small fluid collection in the gallbladder fossa in 10% to 28% of postoperative patients
Large size collections: danger... Bile leak after LC Massoumi et al. J Clin Gastro 2007
Mergener et al Gastrointest Endosc 1999 Bile leak after LC 80 cases of bile leak diagnosed by ERCP
Stent alone: 40 patients - 98% resolution
Sphincterotomy + Stent: 31 patients - 100% resolution
Sphincterotomy alone: 18 patients - 67% resolution

Also: surgical procedures were needed more in the sphincterotomy
alone group .... STENT Massoumi et al. J Clin Gastroenterology. 2007.
Mergener et al. Gastrointest Endosc. 1999. Should the stent be physically long enough to bridge the site of the leak?

Not necessary in most cases Bjorkman DJ Am J Gastroenterol. 1995. Cochrane collaboration report AUTHORS' CONCLUSIONS

Prophylactic drains harm patients

...But, what about after cholecystectomy
for acute cholecystitis? Goal: evaluate the rate of clinical and subclinical bile leaks after LC
for acute cholecystitis. N=100
Postoperative Day 1, the patient underwent cholescintigraphy
(PIPIDA scan)
Results: 8 scans positive for bile leaks.
No patients experienced a clinically symptomatic leak.

Laparoscopic cholecystectomy is a safe and effective treatment for
acute cholecystitis with acceptable rates of clinical and subclinical bile
leaks. Bile leak after LC: Drain after acute LC? Dominguez et al. American Surgeon. 2006. Early Complication Hemmorrhage Injury to viscera Retained stones and abscess
formation
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