International Journal of Hepatology

International Journal of Hepatology / 2016 / Article

Clinical Study | Open Access

Volume 2016 |Article ID 2647130 |

Abu Bakar Hafeez Bhatti, Faisal Saud Dar, Haseeb Zia, Muhammad Salman Rafique, Nusrat Yar Khan, Mohammad Salih, Najmul Hassan Shah, "Prognostication of Learning Curve on Surgical Management of Vasculobiliary Injuries after Cholecystectomy", International Journal of Hepatology, vol. 2016, Article ID 2647130, 6 pages, 2016.

Prognostication of Learning Curve on Surgical Management of Vasculobiliary Injuries after Cholecystectomy

Academic Editor: Daisuke Morioka
Received12 Mar 2016
Revised19 Jun 2016
Accepted22 Jun 2016
Published20 Jul 2016


Background. Concomitant vascular injury might adversely impact outcomes after iatrogenic bile duct injury (IBDI). Whether a new HPB center should embark upon repair of complex biliary injuries with associated vascular injuries during learning curve is unknown. The objective of this study was to determine outcome of surgical management of IBDI with and without vascular injuries in a new HPB center during its learning curve. Methods. We retrospectively reviewed patients who underwent surgical management of IBDI at our center. A total of 39 patients were included. Patients without (Group 1) and with vascular injuries (Group 2) were compared. Outcome was defined as 90-day morbidity and mortality. Results. Median age was 39 (20–80) years. There were 10 (25.6%) vascular injuries. E2 injuries were associated significantly with high frequency of vascular injuries (66% versus 15.1%) (). Right hepatectomy was performed in three patients. Out of these, two had a right hepatic duct stricture and one patient had combined right arterial and portal venous injury. The number of patients who developed postoperative complications was not significantly different between the two groups (11.1% versus 23.4%) (). Conclusion. Learning curve is not a negative prognostic variable in the surgical management of iatrogenic vasculobiliary injuries after cholecystectomy.

1. Introduction

Around 750000 cholecystectomies are performed in the United States annually [1]. Laparoscopic cholecystectomy offers several advantages including less wound pain, better cosmesis, and early return to normal activity. Main disadvantage is a slightly higher risk of biliary injury than open cholecystectomy, that is, 0.5% versus 0.2% [24]. Variations in biliary anatomy, failure in identifying these variations, and a rising trend of performing cholecystectomy in the acute phase of inflammation may lead to more frequent occurrence of biliary injuries [1, 5]. In addition, use of laparoscopic approach not only provides environment more conducive to occurrence of iatrogenic bile duct injury (IBDI) but also increases the risk that these injuries would not be identified intraoperatively [1].

Once a biliary injury has occurred, surgical repair by experienced hepatobiliary surgeon is the most critical factor determinant of outcome [6]. It has been shown that outcomes of surgery for biliary injuries even in specialized centers have a learning curve. What constitutes a learning curve is unclear but 10–15 repairs a year have generally been referred to as “learning curve periods” by experienced centers [7, 8]. It has been shown that quality of life in patients who suffer an IBDI is compromised even after 10 years of successful intervention, costs up to 182,000 (hospital and society) pounds, and is frequently associated with malpractice litigation [9, 10]. As many as 9 different techniques have been developed to identify biliary anatomy preoperatively and intraoperatively and prevent IBDI, critical view of safety (CVS) being the one best validated [10]. With such impact of IBDI on patient lives, there are certain questions regarding associated vascular injuries in IBDI that remain unanswered. We remain unaware of the exact incidence of vascular injuries associated with biliary injuries, their impact on operative morbidity and long term biliary complications, and role of hepatectomy [11]. This raises the question that whether new HPB centers in their learning curve should embark upon IBDI associated with vascular injuries.

The objective of the current study was to demonstrate results of IBDI repair in a new HPB center during its learning phase and determine impact of concomitant vascular injuries on outcome.

2. Methods

We retrospectively reviewed patients who underwent surgery for iatrogenic biliary injuries at Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, between August 2011 and December 2014. All patients were referred from other centers and no IBDI was experienced in our department. A minimum follow-up of 3 months was assured to correctly document 90-day morbidity and mortality.

All patients were seen at HPB out-patient clinic or emergency. A thorough history and physical exam were followed by relevant lab tests. We performed MRCP/ERCP for preoperative assessment of biliary tree depending upon patient’s presentation and previous investigations. In addition dynamic CT scan liver was performed in all patients to assess vascular injuries and liver. These patients were discussed in a multidisciplinary team before a treatment plan was formulized. This team comprised of gastroenterologists, radiologists, and surgeons. Patients who had a failed ERCP or were not candidates for ERCP underwent surgical exploration. For classification of biliary injuries, we utilized Strasberg’s classification [12]. Various biliary injuries (bile duct injuries) based on Strasberg’s classification have been described as follows.A:leak from cystic duct or an accessory duct.B:occlusion of an accessory duct with no continuity with common bile duct.C:leak from bile duct with no continuity with common bile duct.D:lateral and partial injuries to main bile ducts without complete loss of continuity.E1:complete section of common bile duct; CHD stump > 2 cm.E2:complete section of common bile duct; CHD stump < 2 cm.E3:no CHD available, but right and left hepatic duct confluence intact.E4:loss of confluence with no communication between right and left hepatic ducts.E5:aberrant right sectoral duct involved alone or in combination with CHD stricture.For grading of complications Clavien-Dindo grading system was used [13].

We generally used right subcostal incision but, in case a patient was operated on before, scar of previous surgery was used. Roux-en-Y hepaticojejunostomy was performed in all patients and a single drain was placed near anastomosis. After operation, patients were kept in surgical step down for one day before being shifted to the ward. Broad spectrum antibiotics were administered in the postoperative period given the previous history of biliary peritonitis or obstructive jaundice.

For the purpose of this study, patients were divided into two groups, that is, Group 1 IBDI and Group 2 IBDI with vascular injury. The two groups were compared for variables including demographics, predominant symptoms, past history of surgeries, and endoscopic intervention. Operative variables including type of biliary injury, associated vascular injuries, and type of repair were also compared. Outcome was assessed on basis of 90-day morbidity and mortality. Categorical variables were assessed using chi square and Fischer’s test while -test was used for interval variables. SPPS version 20 was used for statistical analysis. The study was performed in accordance with declaration of Helsinki. It was a noninterventional study and no potential identifiers were present. Hospital ethics committee granted exemption from formal review of this study (IRB number 582-030-2016).

3. Results

A total of 39 patients underwent surgical management of IBDI. Median age of our cohort was 39 (20–80) years. Male-to-female ratio was 1 : 5.5. Median time to cholecystectomy and presentation was 72 (3–920) days in patients with associated vascular injury and 312 (5–5436) days in patients without vascular injury and was not significantly different (). There were 9 (23%) patients with concomitant vascular injuries. No difference was observed between Groups 1 and 2 with respect to gender, presenting symptom, surgical access, and radiological interventions as shown in Table 1.

IBDI with vascular injuryIBDI value


Presenting symptomAbdominal pain555.51446.60.4
Bile in drain111.113.4


Radiological interventionERCP666.72376.60.2

3.1. Operative Details

Table 2 demonstrates types of vascular and biliary injuries in our patients. Based on Strasberg’s classification of biliary injuries, 27 (69.2%) patients had E3 and E4 injuries. All patients underwent Roux-en-Y hepaticojejunostomy. There were 9 (23%) patients with 10 (25.6%) vascular injuries. All patients except 1 had injury to right vascular structures. In this patient left portal vein was also injured and thrombosed along with right hepatic artery. She was managed with hepaticojejunostomy and PTFE graft from main portal vein to left portal vein. Only one patient underwent right hepatectomy due to combined arterial and portal venous injury. Other patients with vascular injuries were managed with HJ alone. A right hepatectomy was performed in three patients. Out of these, two had a right hepatic duct stricture associated with right lobe atrophy and one patient had combined right arterial and portal venous injury with resultant liver infarction.


Type of injuryC25.2

Type of vascular injuryRight PV ligated12.6
Left portal vein thrombosis12.6
Right PV thrombosis12.6
Right hepatic artery clipped37.8
Right hepatic artery ligated410.2

3.2. Outcome

Mean follow up time was