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Bile duct Injury During Cholecystectomy: Audit of 1,437 Laparoscopic and Open Cholecystectomy

การบาดเจ็บต่อท่อน้ำดีระหว่างผ่าตัดถุงน้ำดี: ทบทวนเวชระเบียนผู้ป่วย 1,437 ราย

Setthabutr Eaupanitcharoen (เศรษฐบุตร เอื้อพานิชเจริญ) 1

หลักการและวัตถุประสงค์: การผ่าตัดถุงน้ำดีมีภาวะแทรกซ้อนที่สำคัญคือการบาดเจ็บต่อท่อน้ำดีระหว่างผ่าตัด ซึ่งทำให้เกิดผลเสียต่างๆในระยะยาวแก่ผู้ป่วย การศึกษานี้มีวัตถุประสงค์เพื่อทบทวนการผ่าตัดถุงน้ำดี ความชุกของการเกิดการบาดเจ็บต่อท่อน้ำดีในระหว่างผ่าตัด

วิธีการศึกษา: การศึกษาย้อนหลังจากเวชระเบียนของผู้ป่วยอายุ 18 ปีขึ้นไปที่มาผ่าตัดถุงน้ำดี ตั้งแต่วันที่ 1 มกราคม 2553 ถึงวันที่ 31 ธันวาคม 2557 ในโรงพยาบาลมหาราชนครราชสีมา

ผลการศึกษา: จากการศึกษา ผู้ป่วย 1,437 ราย พบความชุกของการบาดเจ็บท่อน้ำดีร้อยละ 1.32 โดยเกิดระหว่างการผ่าตัดแบบส่องกล้องมากกว่าผ่าตัดแบบเปิด แต่ไม่มีนัยสำคัญทางสถิติ (p=0.08) ผู้ป่วยที่มีการบาดเจ็บต่อท่อน้ำดีส่วนใหญ่ได้รับการวินิจฉัยระหว่างผ่าตัด หรือภายใน 14 วันหลังผ่าตัด ค่าใช้จ่ายรวมเพิ่มขึ้นจากกลุ่มที่ไม่มีการบาดเจ็บต่อท่อน้ำดีอย่างมีนัยสำคัญทางสถิติ (31,131.00 และ 65,806.05 บาท, p = 0.01) รวมทั้งระยะเวลาการนอนโรงพยาบาลมากกว่ากลุ่มที่ไม่มีการบาดเจ็บอย่างมีนัยสำคัญทางสถิติ ในการศึกษานี้ไม่มีผู้ป่วยที่เกิดการบาดเจ็บต่อท่อน้ำดีเสียชีวิต

สรุป: จากการศึกษานี้พบว่าการบาดเจ็บต่อท่อน้ำดีระหว่างผ่าตัดถุงน้ำดีมีความชุก 1.32% โดยพบระหว่างการผ่าตัดแบบส่องกล้องมากกว่าการผ่าตัดแบบเปิด แต่ไม่มีนัยสำคัญทางสถิติ (p=0.08) การเกิดการบาดเจ็บต่อท่อน้ำดีระหว่างผ่านตัดส่งผลให้เพิ่มระยะเวลาการนอนโรงพยาบาล มีค่าใช้จ่ายเพิ่มมากขึ้น และในบางรายต้องได้รับการผ่าตัดซ้ำเพื่อแก้ไขภาวะดังกล่าว

Background and objective: Cholecystectomy is a common procedure, but bile duct injury is serious problem. This injury causes several consequences such as longer hospital stays and increase cost of treatment and re-operation. This study aimed to investigate the prevalence of bile duct injury during cholecystectomy.

Method: Retrospective review of medical records of patients age more than 18-year-old underwent cholecystectomy between 1st January 2010 and 31st December 2014 at Maharat Nakhon Ratchasima hospital.

Results: From 1,437 patients in this study, 1.32% prevalence of bile duct injury was found. The injury occurred during laparoscopic cholecystectomy more common than open cholecystectomy but without statistical significant (p=0.08). Most of patients with bile duct injury were diagnosed during surgery or during first 2 weeks after the operation. Mean cost of treatment is significant higher in bile duct injury group than non-injury group (31,131.00 vs 65,806.05 baht, p = 0.01) and hospital length of stay also significantly longer. There was no mortality in bile duct injury group.

Conclusion: The prevalence of bile duct injury in this study was 1.32% which occur in laparoscopic cholecystectomy higher than open cholecystectomy but no statistical significance (p=0.08). This leads to longer hospital stay, higher mean cost of treatment and some patients needed to re-operation. 



          Cholecystectomy is a common operation. Open cholecystectomy (OC) was performed as main treatment for benign gallbladder diseases until laparoscopic cholecystectomy (LC) was introduced in the late 1980s and became standard treatment for symptomatic gallstones. Bile duct injury(BDI) is serious complication of open and laparoscopic cholecystectomy. Prevalence of BDI after open and laparoscopic injury are around 0.4-0.9%1,2 and 0.2-0.3%3,4 , respectively. It leads to several consequences such as longer hospital stays, increase cost of treatment, re-operation and liver failure. Both OC and LC are required operations of the surgical trainee. To prevent this complication, in some institute reported structured training program that trainee must have adequate experience in laparoscopic basic training and have minimum number of at least 5 OC before commencing LC5. This study aimed to assess prevalence and characteristic of bile duct injury.


          After institutional ethic review board approval, medical records of all patients age 18 and over who underwent cholecystectomy as a primary procedure in department of surgery, Maharat Nakhon Ratchasima hospital (MNRH) from 1st January 2010 to 31st December 2014 were reviewed. Operative notes of patient who underwent either OC or LC in MNRH will be retrieved from hospital database. Demographic data, indication for surgery, conversion to open surgery, trainee experience in cholecystectomy, operative time and operative blood loss will be recorded. BDI was classified according to Strasberg’s classification3. Time of detection bile duct injury will be classified as intraoperative if BDI detected during surgery, early if detected within or at 2 weeks after surgery and late diagnosis if detected after 2 weeks after surgery. Treatment of BDI was also recorded. Patient who underwent cholecystectomy due to blunt and penetrating trauma, known malignant disease, cholecystectomy as part of other abdominal operations were excluded.


Statistical analysis

          All data were analyzed by R-studio program. Continuous variables were presented as mean and SD or median and IQR where appropriate. Categorical variables were presented as percentage. Independent t-test was used to calculate the significant different in continuous variables and Chi-square test or Fisher’s exact test were used to calculate the significant different in categorical variables where appropriate. Factors that have p value less than 0.05 were considered as statistical significant.


Total 1,437 patients underwent cholecystectomy in 5-year period from January 2011 to December 2014. One thousand and seventeen patients were female (70.8%) and 420 patients were male (29.2%). Age range from 18 to 94-year-old with a mean of 54.19 years. Two third were underwent OC. There were 14 trainees involved during that period. Three hundred and ninety-eight cholecystectomies (27.7%) were performed by surgical trainees (33 LC and 365 OC). There were 19 patients had bile duct injury (1.32%), 2 BDI patients occurred in emergency OC performed by surgical trainees whereas 17 out of 19 BDI occurred in operation performed by attending surgeons. The overall mortality rate was 3.27% (47 out of 1,437), and 43 out of 47 deaths were patients who underwent emergency OC.

In Table 1 shows patient’s characteristics and operative outcomes categorized by types of surgery. Fifty-six patients needed to be converted from LC to OC (10.4%). In this study the mean cost of LC was slightly higher than OC but average hospital length of stay was shorter in LC group (4.45 vs 5.88 days, p <0.001). But if BDI occurred the mean cost of treatment was 2-fold higher (31,131.00 vs 65,806.05 baht, p = 0.01). Almost all emergency patients underwent OC. Diagnosis for patients underwent cholecystectomy were shown in Table 2


Table 1 Patient’s characteristics and operative outcomes categorized by types of surgery




n (%)



n (%)

p value

Age (mean±SD)



< 0.001


413 (76.91)

604 (67.11)

< 0.001

Bile duct injury (%)

11 (2.05)

8 (0.89)


Emergency: elective surgery



< 0.001

Operative time, minutes (mean±SD)




Blood loss (mean±SD)




Hospital stay (mean±SD)




Mortality (%)

- elective

- emergency

2 (0.37)

2 (0.37)


45 (5)

2 (0.22)

43 (4.78)

< 0.001

Cost ,baht (mean±SD)





Table 2 Diagnosis categorized by type of surgery




n (%)



n (%)

Symptomatic gallstone

504 (93.85)

524 (58.22)

Acute calculous cholecystitis 

8 (1.49)

327 (36.33)

Acute acalculous cholecystitis        


11 (1.22)

Gallstone pancreatitis      

19 (3.54)

15 (1.67)

Gallbladder polyp 

6 (1.12)

11 (1.22)

Twisted GB           


8 (0.89)

Chronic cholecystitis          


3 (0.33)

Hydrops gallbladder            


1 (0.11)


As shown in Table 1, BDI were occurred in LC 2 times more common than OC (2.05% VS 0.89%) and most of them occurred during elective surgery (Table 3). Most of these injuries were detected in intraoperative period (52.63%) and within 14 days after surgery (84.21%). Most common type of BDI in this study was type D (47.4%) according to Strasberg’s classification (lateral wall injury) and second most common type was type E2 (42.1%) which most of type E2 injury were occur during LC. None of these patients died. Treatments for these injuries were biliary-enteric bypass in 9 patients, primary repair over t-tube placement in 8 patients and endoscopic treatment in 8 patients.


Table 3  Bile duct injury during cholecystectomy categorized by type of surgery


BDI in LC (n=11)

n (%)

BDI in OC (n=8)

n (%)

Post-operative detection (days)

- intraoperative detection

- early (within 14th day postoperatively)

- delayed (later than 14th day postoperatively)


4 (36.36)

4 (36.36)

3 (27.27)


6 (75)

2 (25)


Starsberg's classification (%)

-Type A

-Type B

-Type C

-Type D

-Type E1

-Type E2


1 (9.09)



4 (36.36)


6 (54.55)





5 (62.50)

1 (12.50)

2 (25)

BDI during emergency surgery


5 (62.50)

Conversion to open surgery

5 (45.45)


Hospital stay (median and IQR)

10.0 (7.0)

10.5 (7.5)

Mortality (%)






BDI during cholecystectomy is a serious complication, increase hospital length of stay, increase cost of treatment, need further surgeries to correct, reduce survival6, impaired quality of life especially in patient who has delayed diagnosis7,8. There are many studies regarding risk factors of iatrogenic bile duct injuries, especially in LC. Most common factor that contributes BDI is misidentification of common bile duct or common hepatic duct as cystic duct. This may be because of variation of biliary anatomy or technical error. This can be avoided by careful dissection of tissue in Calot’s triangle until base of liver is exposed and only 2 structures entering gallbladder are seen, so called “Critical view”3. Other factors are surgeon’s experience, severity of diseased gallbladder, excessive traction on cystic duct with tenting upward of common hepatic duct, improper use of clip to control bleeding9.

In this study number of LC is similar to OC in elective setting, but almost all emergency cases were done by open technique. The prevalence of BDI reported in other studies were 0.4-0.9% in laparoscopic and 0.2-0.3% in open cholecystectomy.  We have comparable BDI rate in OC compare to other studies but higher BDI rate in LC compare to other studies1,3,10–13. This may be because of most of our cases were delayed laparoscopic or open cholecystectomy 2-3 months after successful medical treatment for acute cholecystitis and 17 out of 19 BDI that occurred were done by attending surgeons, this may be suggesting that in complex or complicated cases they were operated by attending surgeons. Average hospital length of stay was shorter in LC as reported in other studies but 4.45 days in LC group was longer than average hospital stay in other studies14–16.  Due to this is retrospective study the information regarding potential factors that may associated with BDI such as body mass index, surgeon’s experience or information about critical view of safety before the cystic duct was clipped were not available.



The prevalence of BDI in this study was 1.32% and prevalence of BDI in LC was higher than OC but no statistical significance (p=0.08). Common types of BDI found in this study were Strasberg’s classification type D and type E2 injury. Most of injury were detected during the operation or within 2 weeks after surgery. Bile duct injury during cholecystectomy is a serious complication, increase hospital length of stay, increase cost of treatment, need further surgeries to correct and need long term follow up. This common operation needs careful and meticulous dissection to prevent bile duct injury.



1.       Karvonen J, Salminen P, Grönroos JM. Bile duct injuries during open and laparoscopic cholecystectomy in the laparoscopic era: alarming trends. Surg Endosc 2011; 25: 2906–10.

2.       Richardson MC, Bell G, Fullarton GM. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 1996; 83: 1356–60.

3.       Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180: 101–25.

4.       Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993; 218: 129–37.

5.       Lim SH, Salleh I, Poh BK, Tay KH. Laparoscopic cholecystectomy: an audit of our training programme. ANZ J Surg 2005; 75: 231–3.

6.       Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile Duct Injury During Cholecystectomy and Survival in Medicare Beneficiaries. JAMA 2003; 290: 2168–73.

7.       Rystedt JML, Montgomery AK. Quality-of-life after bile duct injury: intraoperative detection is crucial. A national case-control study. HPB 2016; 18: 1010–6.

8.       Landman MP, Feurer ID, Moore DE, Zaydfudim V, Pinson CW. The long-term effect of bile duct injuries on health-related quality of life: a meta-analysis. HPB (Oxford)  2013; 15: 252–9.

9.       Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker ME, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 1992; 215: 196–202.

10.     Flum DR, Koepsell T, Heagerty P, Sinanan M, Dellinger EP. Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography: adverse outcome or preventable error? Arch Surg Chic Ill 1960 2001; 136: 1287–92.

11.     Mahatharadol V. Bile duct injuries during laparoscopic cholecystectomy: an audit of 1522 cases. Hepatogastroenterology 2004; 51: 12–4.

12.     Pariani D, Fontana S, Zetti G, Cortese F. Laparoscopic Cholecystectomy Performed by Residents: A Retrospective Study on 569 Patients. Surg Res Pract 2014; 2014: 1–5.

13.     Pekolj J, Alvarez FA, Palavecino M, Sánchez Clariá R, Mazza O, de Santibañes E. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg 2013 ; 216: 894–901.

14.     Grace P A, Quereshi A, Coleman J, Keane R, McEntee G, Broe P, et al. Reduced postoperative hospitalization after laparoscopic cholecystectomy. Br J Surg 2005; 78: 160–2.

15.     Rubert CP, Higa RA, Farias FVB. Comparison between open and laparoscopic elective cholecystectomy in elderly, in a teaching hospital. Rev Col Bras Cir 2016; 43: 2–5.

16.     Ko-Iam W, Sandhu T, Paiboonworachat S, Pongchairerks P, Chotirosniramit A, Chotirosniramit N, et al. Predictive Factors for a Long Hospital Stay in Patients Undergoing Laparoscopic Cholecystectomy. Int J Hepatol 2017; 2017: 5497936.


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