On a sleepy Saturday afternoon, I receive a phone call from a friend and colleague of mine who works in another hospital. He sounds very distressed. Worried, I would say. Extremely worried. He tells me that he “messed up a simple operation of laparoscopic cholecystectomy” and needs my help. I try to calm him down and ask him to explain a bit better, so that I can understand what kind of help he needs. He tells me that he has been doing a surgical list of relatively small operations, “hernias and gallstones, you know”… Unfortunately, the second laparoscopic cholecystectomy was a bit more difficult than expected and he had to work a bit to mobilise the gallbladder. When he thought he had almost completed the operation, he saw bile on the operative field. Trying to find the source of that bile leak, he saw a completely severed duct, pouring clear bile, deep into the liver. He decided to complete the cholecystectomy and remove the gallbladder, but looking at the specimen he realised that he had removed not only the gallbladder and cystic duct but also a tract of the common bile duct. As soon as he understood the gravity of that complication, he panicked but correctly decided not to try to fix the problem himself, as he felt he is not completely confident to work on the biliary ducts, in particular in emergency situations. The next step was to position an abdominal drain and close the operation. Of course, I accept the transfer of the patient, who is shipped with a blue-lights car as soon as he is able to tolerate the transfer.
Injuries of the bile duct during cholecystectomy can be considered a sort of pandemic. The overall risk is quite low, about 0.1% of all cholecystectomies, but if we consider that every year millions of patients have their gallbladders removed, it becomes evident that the number of bile duct injuries per year is extraordinarily high. Actually, biliary injuries show a wide spectrum of gravity, i.e., a small leak of bile from the liver is normally self-resolving within few days while at the other end of the spectrum, a complete transection of the main bile duct may need multiple complex procedures that can end up with a liver transplantation. An injury of the biliary tract depends on a lot of factors, including extensive inflammation of the gallbladder, intraoperative bleeding, abnormal anatomy, but also overconfidence – or lack of experience – of the surgeon. These complications can be discovered during the operation, in the early postoperative period or weeks/months after the cholecystectomy.
The presence of non-gallbladder bile in the surgical field during cholecystectomy means that a bile duct has been injured. If the surgeon is an expert biliary surgeon or there is one readily available, the next step would be to perform an accurate dissection (and also an x-ray examination) to understand what duct has been injured and how it can be repaired. Often, the repair can be performed immediately, if a surgeon with expertise in biliary reconstruction is available. Otherwise, performing a dissection of the bile tree at the hepatic pedicle is a potentially dangerous procedure that can worsen an already challenging situation if the surgeon is not perfectly acquainted with that anatomy and the reconstruction techniques. If this is the case, it is much safer to stop the operation, leave a drain to guide the bile out (and avoid accumulation of bile into the abdomen) and transfer the patient to a tertiary hepatopancreatobiliary unit.
Another possibility is that the operation is completed as usual but one or two days afterwards the patient starts complaining of abdominal pain and sometimes fever. He or she can be septic and/or jaundiced. Clearly, if the patient has already been discharged, he or she must seek urgent medical attention, as there is a strong possibility of a biliary injury, either in the form of a leaking lesion or a stricture. At this point the patient should be directly referred to a tertiary subspecialist unit where all the necessary investigation and treatments can be offered. Usually, the first investigation is a CT scan of the abdomen, to rule out collections or other issues. A biliary magnetic resonance imaging (known as MRCP – magnetic resonance cholangio-pancreatography) is mandatory to understand exactly where the bile leak or stricture is and to have a precise idea of the biliary anatomy. An endoscopic retrograde cholangiopancreatography may be the next step, to try and put a stent in the bile duct if indicated. In most cases, stenting is enough to allow a progressive healing of a small defect, but larger injuries may need a surgical operation of biliary reconstruction. Biliary reconstruction entails joining the severed duct to a loop of small bowel, thus allowing drainage of the bile into the bowel, as it should be. The problem is always to find the best timing for the operation as a too late operation would increase the risk of sepsis but a too early operation would sometimes be unsafe due to local conditions. If the patient is septic, meaning that there is a severe infection in the abdomen, the treatment of sepsis is paramount and has priority on any reconstruction.
In rare cases, a biliary injury can be discovered weeks or months after a cholecystectomy when the patient comes back for jaundice and pain. Usually, the responsible of these symptoms at such a distance from the cholecystectomy is a stricture of the biliary duct. Sometimes the stricture can be dilated and stented endoscopically, but most patient would need a surgical repair at some stage.
Irrespective of the injury being discovered intraoperatively, early during the postoperative period or later on, these patients may need multiple procedures, such as percutaneous drainage or endoscopic stenting, before a reconstruction can be achieved. For this reason, biliary injuries must be treated by an experienced multidisciplinary team where surgeons, endoscopists, radiologists, microbiologists, intensivists and gastroenterologists gather together to offer the best tailored approach to each single patient.
In the case I have described above, the injury was discovered during the operation and my colleague who did the operation correctly did not try to repair the injury by himself, as he did not feel perfectly confident to perform a complex biliary reconstruction. He did the best thing he could safely do for his patient, transferring him to our Unit. We performed a very early reconstruction, the day after the injury. We could do that because the patient was young and fit and could tolerate a second operation in two days and mostly because we knew the bile leak was completely drained outside. On the contrary, more often in these cases we would avoid performing a surgical repair too early and prefer to “stabilise” the bile leak and “guide” it outside for a while, meaning it would be many weeks or months before we could perform a safe and effective reconstruction. In the case described, we were confident that an early repair would work, and the operation was straightforward. The patient recovered well and was discharged home within a week.
Biliary injuries during cholecystectomy are one of the main reasons for medicolegal claim. This is perfectly understandable, because cholecystectomy is usually a straightforward operation and patients expect to go home very soon after the operation, possibly on the same day, and in almost perfect conditions. The nasty complication hereby described prolongs the recovery time of several weeks and sometimes leaves permanent stigmata that can limit the patient’s quality of life, therefore some patient feels entitled to a compensation. While this is perfectly acceptable and allowed by law, it is important that every patient understands that there is no such a thing as a “easy” operation. Sometimes, cholecystectomies can be extremely tricky, and the risk of complications is much higher than reported in worldwide overall statistics. Patients themselves may also have a negative role. Not going to the doctor in time but waiting until symptoms are unbearable can make the inflammation progress and when the surgeon operates to remove the gallbladder, he/she finds extensive adhesions and fibrosis, preventing the correct identification of the biliary anatomy and causing misperception. It is important to understand that a biliary injury is usually not related to negligence, imprudence, or inexperience, but it is something that can happen at any time, despite any effort to avoid it. Miscommunication between the doctor and the patient is one of the main factors causing medicolegal issues, as patients complain of lack of a complete and honest information before and after the operation. Doctors must learn and accept that communication is a crucial part of our job and has the same importance – if not more – than the surgical performance. Well informed patients are less likely to raise medicolegal claims because they feel involved in the medical decisions and looked after during their clinical course, accepting that negative outcomes can happen and can be resolved with a strict collaboration between patients and surgical teams.
Biliary injuries during cholecystectomy have a profound impact also on the surgeon, who is considered the second victim of the complication because of the deep psychological impact of the negative event on the surgeon’s mind, professionalism and career.
Biliary injuries can also have a negative impact on the whole society. The story of the former British Prime Minister Sir Anthony Eden is well known. Briefly, when he was still Foreign Secretary, he developed biliary pain and probably jaundice and underwent an open cholecystectomy. Unfortunately, he had a complex injury of the bile duct and underwent a biliary reconstruction in Boston by Dr Cattell. Unfortunately, the bilioenteric anastomosis fashioned to permit a normal bile flow became progressively narrow, thus causing pain and fever. It is alleged that pain killers and amphetamines used to control that pain impaired Eden’s political acumen when he became Prime Minister and might have caused the excessive military response to the nationalization of the Suez Canal by the Egyptian President Nasser in 1956, involving Israel and France in what has been recorded as the Suez Crisis, that created a huge political turmoil and increased the risk of a Third World War.
If you want to read more about bile duct injuries and their impact on patients, doctors, and society, feel free to read: