Laparoscopic biliary injury: more than a learning curve problem.

BACKGROUND The increase in the incidence of iatrogenic injury to the extrahepatic biliary tree that has been documented since the introduction of laparoscopic cholecystectomy (LC) has been explained as a 'learning curve' problem. The early New Zealand experience has been published and the present study was undertaken to determine whether there had been any change in the incidence, nature and management of laparoscopic biliary injuries (LBI) after further experience with LC. METHODS A nationwide audit was undertaken in 1995 by two confidential postal questionnaires: to all active general surgeons (n=184, response rate 60%), and to all endoscopists performing endoscopic retrograde cholangiopancreatography (ERCP) (n=18, response rate 100%). RESULTS The total number of LBI was 21, compared with 41 for 1991-92. The site and nature of the injuries were similar for the two survey periods. More of the injuries appeared to be diagnosed after the operation and prior to discharge (25% vs 47%). Calculating the national incidence of LBI was not possible without complete reporting, but in the subset of surgeons responsible for the LBI there was no apparent decrease in the incidence of all LBI (2.8% vs 2.9%), those requiring active re-intervention (2.4% vs 2.7%) and major duct injury (1.1% vs 0.7%), despite a significant increase in the surgeons' prior experience with LC (20% vs 61% of surgeons had performed more than 100 LC). There were some concerning trends in management: a less frequent use of ERCP in patients with LBI diagnosed after surgery (76% vs 65%) and a higher proportion of patients with minor injuries managed by re-operation (26% vs 50%). CONCLUSIONS The present study indicates that iatrogenic biliary injury is a persistent problem in New Zealand, despite increasing experience with LC, and suggests the need for more intensive scrutiny of operative technique and training. There is scope to manage more patients with minor duct injuries conservatively.

[1]  J. Ponsky.  Endoscopic approaches to common bile duct injuries. , 1996, The Surgical clinics of North America.

[2]  N J Soper,et al.  An analysis of the problem of biliary injury during laparoscopic cholecystectomy. , 1995, Journal of the American College of Surgeons.

[3]  C. Mcsherry.  Cholecystectomy: the gold standard. , 1989, American journal of surgery.

[4]  M. Cohen,et al.  Has laparoscopic cholecystectomy changed patterns of practice and patient outcome in Ontario? , 1996, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[5]  A. Kruse,et al.  Endoscopic management of postoperative bile leaks , 1992, The British journal of surgery.

[6]  J. Hunter.  Avoidance of bile duct injury during laparoscopic cholecystectomy. , 1991, American journal of surgery.

[7]  P. O’Dwyer,et al.  Bile duct injury and bile leakage in laparoscopic cholecystectomy , 1995, The British journal of surgery.

[8]  P. O’Dwyer,et al.  Preventing complications of laparoscopy , 1993, The British journal of surgery.

[9]  D. Fletcher.  Changes in the practice of biliary surgery and ERCP during the introduction of laparoscopic cholecystectomy to Australia: their possible significance. , 1994, The Australian and New Zealand journal of surgery.

[10]  W. Meyers,et al.  Management of Major Biliary Complications After Laparoscopic Cholecystectomy , 1993, Annals of surgery.

[11]  O. Garden.  Iatrogenic injury to the bile duct , 1991, The British journal of surgery.

[12]  S. Eubanks,et al.  1525 laparoscopic cholecystectomies without biliary injury: a single institution's experience. , 1995, The American surgeon.

[13]  G. Berci,et al.  Continuing hazards of the learning curve in laparoscopic cholecystectomy. , 1995, The American surgeon.

[14]  Sankey V. Williams,et al.  Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. , 1996, Annals of surgery.

[15]  D. Vokes,et al.  Early laparoscopic biliary injury: Experience in New Zealand , 1994, The British journal of surgery.

[16]  D. Fletcher.  Biliary injury at laparoscopic cholecystectomy: recognition and prevention. , 1993, The Australian and New Zealand journal of surgery.