Biliary complications
Non-biliary complications
Residual stones
0.3–18 %
Operative wound (infection)
0.1–7.9 %
Biliary fistulae
0.1–0.4 %
Haemorrhage
0.2–2.2 %
Biliary tract lesions
0.1–0.8 %
Respiratory problems
2.0–5.3 %
Pancreatitis
0.5–1.0 %
Deep vein thrombosis
0.6–1.3 %
Bowel occlusion
0.3–0.7 %
Vascular stroke
0.8 %
Pulmonary embolism
0.3–1.0 %
On the whole, a little less than the previous mentioned ones, it is necessary to consider that some patients have more than one complication.
Non-biliary complications are the usual ones, known in general, and possible in any case of abdominal surgery; we are not going to talk about it in this chapter, concentrating our comments on the biliary ones and, amongst these, in the iatrogenic lesions to the biliary tract. These can be detected immediately, during surgery, in the early postoperative period or late, sometimes even months after surgery. What is also important is that about 2/3 of these lesions are not detected during surgery.
Nevertheless, we have to mention that some haemorrhage can be avoided by paying special attention to local factors: for instance, patients with coagulation disturbances or with portal hypertension may have to be dealt with by different solutions like a partial Torek’s cholecystectomy. In addition, the draining vein running within liver parenchyma, sometimes rather superficial, in the gallbladder bed, shall be avoided by taking all necessary steps not to go deep during the lifting of the gallbladder from its liver bed [4] (Fig. 2.1). If bleeding comes from this vein, control may be hazardous. The gallbladder shall be dissected from its bed by “lifting” it and by simple separation, without being necessary to do any sharp cutting in general. In cases of acute cholecystitis or of strong adhesions after several inflammatory episodes, this may be necessary, but it is then when all surgeons shall be over attentive and when all cautious movements shall be put into practice.
Fig. 2.1
Vein at gallbladder’s bed and its frequency of depth [4] (Photo – courtesy of Dr. Jaime Roque)
Obviously, it is supposed that elective patients have a complete workout, where alterations like abnormal blood clotting will be detected and proper measures taken.
Within the biliary complications, the contents of this chapter will focus mainly in the iatrogenic lesions.
2.2 Causes (“Why” It May Happen)
If we look at the possible causes of complications, we have several variables to consider. These depend on the patient’s general condition and comorbidities, on the type and seriousness of the disease, on the training and expertise of the surgeon, on the quality and existence of all pieces of equipment necessary and on the hospital environment.
Another frequently mentioned variable, in what concerns laparoscopic surgery, is the so-called learning curve. But, although this “learning curve” can be responsible for many things and has to be eliminated or minimised as much as possible, it has no defined causal relation to BDI; the “learning curve” for laparoscopic cholecystectomy goes well beyond 50 cases, and, although operating time keeps lowering until 200 cases, improvement in the cognitive skills to deal with difficult cases continues [5].
It has also been shown that the risk goes beyond “first cases”, as demonstrated in the following series from the same institution: first 1284 cases (0.58 % BDI) and next 1143 cases (0.50 % BDI) [6]. An enquiry into 1500 surgeons reports that about 30 % of BDI occur after the first 200 cases [7]. We can only conclude that surgeon’s experience does not minimise the risk.
This persistence of high rates of BDI after the initial training curve shows that there is a difference in these; it is considered that there is a difference between “experienced” surgeons and “experts”. “Experts” are surgeons with “consistently better outcomes” (namely, BDI rates, consistent and very low or close to zero).
Some local factors have shown to be responsible for a higher incidence of complications: local inflammation is a well-known one, even conditioning the timing of surgery for acute cholecystitis; fibrosis, reoperations with “changed” anatomy or urgent surgery are other causes. Also, local adhesions or bowel distension can be a reason.
Choice of wrong timing to operate acute cholecystitis is a common cause for surgical difficulties and eventually surgical accidents. There is evidence that performing cholecystectomy more than 5 or 6 days after the onset of the acute inflammation will make surgery much more difficult and face a great number of serious inflammatory adhesions, causing much more bleeding than usual and making it difficult to recognise proper anatomy and surgical landmarks.
Some signs, visible previously to surgery or during it, shall lead to the suspicion that serious inflammation may be present; thick gallbladder wall (>5 mm) at US, firm adherence of gallbladder to omentum, duodenum, colon or stomach, liver pulled down around a shrunken gallbladder or when the surgeon cannot find the gallbladder are some of these.
Before following on to other possible causes, let us summarise patient’s ones. One must not forget who the high-risk patients for iatrogenic lesions are:
Male patients
Patients with cirrhosis or liver steatosis
Obese patients
Those having had previous upper abdominal surgeries
Those having delayed treatment of acute cholecystitis
A multitude of technical mishaps are causes for complications, most of them being present due to the ineptitudes of the surgical team and from some of its technical options:
Bad ports positioning, in the case of laparoscopic approach, is an evident cause, but many times these are not properly weighed. By itself, or because of the above, a bad field exposition and bad illumination are also reasons for a higher incidence of complications. Too much smoke or too much blood in the field can hamper visibility to a point of danger.
There is a need to have the ports correctly positioned regarding the possible location of the gallbladder, patient’s BMI and configuration and size of the instruments being used.
In the same line, bad anaesthesia is a well-known factor by contributing to bad visualisation of the operating field; patient’s lack of relaxation will “close” the operating field.
Surgeon’s (or team’s) inexperience as well as surgeon’s (or team’s) tiredness are very often disregarded or not recognised. In connection with these factors is not knowing of eventual anomalies; these anomalies are frequent, well known and defined and represent a serious situation, which, if not recognised, give no excuses to the surgeons involved. No surgeon shall undertake any kind of surgery without minimal theoretical and practical preparation, much more so in the biliary field, where important anomalies are so frequent. On the other hand, also related to “experience”, surgeon’s overconfidence can be a cause of BDI, by “simplifying” some cases or some technical steps of surgery.
The surgeon can, still, be a cause of BDI, by not paying attention to some crucial points: performing surgery with a bad vision angle, using wrong instruments and applying wrong use of technologies are, too often, causes of lesions.
In a similar level, technical failures come as causes for complications; some of these are surgical technique failures, some instrumental ones. Inappropriate traction of structures, supposedly for “better exposition”, can alter the anatomical relations and be a cause of lesions; the same goes for undue use of diathermia, which, unfortunately, we see too often, either by using it too strongly or for too long. Another point for which care is mandatory relates to proper maintenance of instruments; especially reusable ones can have deficient isolation, giving rise to coupling lesions, when, while using electrosurgery, non-visible sparks jump from the instrument to organs away from vision, with consequent thermal lesions.
Instrumental mishaps are, sometimes, unavoidable, but their occurrence must be anticipated, and backup material and/or appropriate maintenance and repair are a must. Instruments can be broken, tipped or sharp pointed, can be inappropriate for the task or can mechanically malfunction.
Let us look at an important point related to these issues: human error. The so called “learning curve”, with its associated human error, which is so often used nowadays in surgery as an “explanation” for some complications, would never be accepted in high-technology industries or in some sensitive areas like airlines or military. Many mandatory preparation steps have been designed by these groups to impose rules and protocols, in order to minimise the problems; soon we may have to do the same and follow, for instance, a complete checklist procedure before and during each surgical operation; checklists are a controversial point to be discussed under a different approach. Training, on the other hand, is a capital issue and it is necessary to keep full attention to this sector.
Human errors can happen, nevertheless, despite all efforts to avoid them; we have to minimise them to the extreme. More often, they are based on technical, training or knowledge failures (ignorance) and with non-compliance to established rules. These are the ones “easier” to control. Others are related to a complex and not well-known phenomenon: visual failure or misguidance.
Included amongst processes called “heuristic”, human brain can induce visual errors that, no matter what further obvious changes there are in the visual field, become stable and understood as reality, staying like that for the whole surgery. This means that, under certain circumstances, anatomic structures are perceived as different ones in the beginning of the surgery (the most common one being interpreting the CBD as being the cystic duct), and the brain “keeps telling” that this first perception is the correct one, leading to the crucial iatrogenic lesion [8].
In a more practical example, this process can also be called “optical illusion” and is well exemplified in the two drawings below: in one, called the Kanizsa’s triangle, half of the viewers will see a black-lined triangle, the other half a white one; the other drawing will show six or seven cubes piled in different directions, again depending on the first view of the observer. As a matter of fact, in Kanizsa’s triangle, there is no triangle: just three angles and three “Packman drawings”, which, in togetherness, compose the image(s) that the brain “thinks” to be the right one (see Figs. 2.2 and 2.3).
Fig. 2.2
Kanizsa’s triangle
Fig. 2.3
Way and Lawrence have shown in 2003 that the great majority of iatrogenic lesions of the biliary tract (97 %) are caused by errors in visual perception and only 3 % because of technical errors (Fig. 2.4).
Fig. 2.4
Rate of technical (3 %) and non-technical (97 %) causes of errors leading to iatrogenic bile lesions
This means that most lesions are caused by “intentional” actions by surgeons (not realising it, evidently), leading to unintentional results. These errors of visual perception can be caused – besides the basic problem – by visual difficulties under special situations: inflammation, too much cephalic retraction and, at the same time, insufficient lateral retraction, and “camel hump” position of the CBD because of too much upper traction of the gallbladder infundibulum [9].
2.3 Prevention (with Tips and Tricks)
Many of the explanations for the “causes” are, at the same time, self-explaining regarding what has to be done for “prevention” of the complications.
We can consider that one of the most important issues, which allow minimisation of complications, is correct indication and preparation of patients for any given surgery. Fast-track is also a possibility for these patients, but let us not forget that the whole concept of fast-track does not allow “forgetting” to apply all necessary steps.
All these factors lead to “paradigms of avoidable error”, which are a challenge for every surgeon involved in biliary surgery.
The questions and paradigms are:
Can the use of a meticulous technique and of an intense effort to identify the anatomy avoid lesions?
It is known that prosecuting “excellency” can diminish the rate of complications, but can it ever avoid it completely?
Will the results of any working group or surgeon always be conditioned by statistical compilations?
Statistically, it can still be said that, despite all efforts, a lesion of the biliary tract will always occur, at least once during the career of any GI surgeon. Because of this, in the end, and the most important: are complications inevitable??
While the goal should really be minimising harm, this does not seem at the moment completely avoidable. Only a culture of prosecution of quality and excellence, using all means at our disposition and implementing checklists, protocols, compliance of rules and proper training, can lead, eventually, to ground zero of complications. Checklists, as mentioned before, are a subject to be discussed in detail elsewhere.
Strasberg has defended, for quite some time now, that the systematic use of the so-called “Critical View of Safety” (CVS) – his dissection technique – can prevent the occurrence of iatrogenic lesions; in some countries, it is mandatory to use this dissection approach and to provide evidence of its use, the best evidence being provided by images, either video or still photos [10]. CVS dissection consists of performing a dissection, which ends up by showing only two structures coming to the gallbladder fundus (cystic duct and cystic artery) (Fig. 2.5). This dissection technique has been favourably compared to the “funnel” one, also called “infundibular”, coming from above, which risks confusion between CBD and cystic duct. Nevertheless, CSV dissection can be pretty difficult to achieve in “the difficult” gallbladder. We believe that these cases demand a much more meticulous dissection, step-by-step until a close to CVS view can be obtained.
