Laparoscopic biliary tract injury: what are the limits of prevention?

At the joint meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Hepato-Pancreatic-Biliary Association in April 2005, the program committee convened a forum on the subject of biliary injuries that occur during laparoscopic cholecystectomy. More than 300 surgeons attended this forum, and the discussion was lively, indicating that this topic still is important to practicing surgeons. The editors of Surgical Endoscopy have agreed to publish the papers from this forum in this issue of the journal [1, 2, 5, 6, 8]. There are two articles on the prevention of biliary injuries during cholecystectomy and there are three papers on methods for diagnosing, evaluating, and treating the problem once it has occurred. The editors are to be commended for agreeing to print these proceedings because, they are written by experts in the field and are very informative to all surgeons who treat patients with biliary tract disease. The questions are (1) How safe can we make laparoscopic cholecystectomy? and (2) How much can we reduce the rate of bile duct injury? The answer to both questions is that laparoscopic cholecystectomy should certainly be as safe as open cholecystectomy, with a comparable or lower incidence of biliary injury. In this commentary, I review the highlights of the presentations at the symposium and present my observations on the issue of biliary injury. Cholecystectomy for gallstone disease is one of the most common procedures performed by general surgeons in North America. The introduction of laparoscopic cholecystectomy in the early 1990s stands out as one of the most significant new developments in the practice of surgery for the past three decades. Not only did it dramatically change the management for one of the most common surgical conditions—cholelithiasis; it also ushered in the new era of minimally invasive or laparoscopic surgery, which has been successfully applied to many other intraabdominal and thoracic disorders. This new procedure was quickly accepted and adopted by patients, referring doctors, and industry. The benefits of the laparoscopic approach were readily apparent and included a shorter hospital stay, a shorter recovery period, decreased postoperative pain, and a quicker return to normal activity. Unfortunately, along the way, it became apparent that an increase in the rate of biliary tract injuries was associated with laparoscopic cholecystectomy. In the 1990s, several groups reported that the incidence of bile duct injuries had risen from 0.1% to 0.3% for open cholecystectomy to 0.4% to 0.6% for the laparoscopic approach, which was a doubling of the incidence [3, 4, 7, 11]. Initially, these data were viewed as a reflection of the learning curve for this procedure. However, over the next two decades, the results did not change. Injuries to the bile duct continue to occur although the current generation of surgeons grew up in the laparoscopic era. Any improvement or reduction in the incidence and frequency of biliary tract injuries during cholecystectomy will come about only as a result of specific instruction and attention to anatomic detail. Continuing education programs for surgeons in practice and good teaching for our residents in training with continued emphasis on proper technique and precautions are key components. The price to pay for the complications of a biliary tract injury is indeed considerable. The morbidity of these complications is reflected in additional procedures and operations, cholangitis, intraabdominal infection, biliary cirrhosis, and, in extreme cases, endstage liver disease and death. Dr. Traverso opened the aforementioned forum with a presentation on the routine use of intraoperative cholangiography (IOC) as a valuable tool for lowering the risk of bile duct injury during cholecystectomy. He emphasized the diverse pattern of the biliary anatomy and the importance of recognizing biliary anomalies and variations. For him, routine IOC is key to identifying Correspondence to: G. M. Larson Editorial