Complications of
Laparoscopic Cholecystectomy

Besides all other complications associated with access and pneumoperitoneum, the most common complications associated with the procedure itself are bleeding, duct injuries, and intestinal perforation along with other less common ones.

Mechanism of injury
Misidentification of anatomy appears to be the most common cause of laparoscopic bile duct injury. The most common scenario, initially described by surgeons at Duke University as the “classic" Injury, occurred in 63% of their patients. The "classic" injury occurs due to mistaking the CBD for the cystic duct which is clipped and divided. Further retraction of the gallbladder then leads to a second higher injury with division of the common hepatic duct as it approaches the bifurcation. This second ductal injury is often described in the operative note as being a 'second cystic duct" or "an accessory duct." This injury is particularly devastating as complete transaction of the biliary tree virtually removes any possibility of non-operative management by either endoscopic or transhepatic technique and mandates biliary-enteric drainage.

Other less common mechanisms of injury include a "tenting injury" in which the CBD is pulled laterally at the time of occlusion of the cystic duct and caught in the clip, thermal injuries due to injudicious use of cautery or laser, excessive application of clips to control bleeding in the area of the triangle of Calot and finally injuries to an aberrant or low-inserting right hepatic duct.

How to prevent?

1.	Lateral retraction of the infundibulum In 1991 Hunter noted that Bile duct injuries with laparoscopic cholecystectomy appeared to be more common in the U.S. (0.5 to 2.7%) than in Europe (0.33%) He observed that American teaching stressed cephalic (towards the Right shoulder) traction on the infundibulum of the gallbladder, tenting the CBD and risking its mis-identification. The cystic duct normally emerges at acute angle to the CBD and this angle actually narrows when the fundus is retracted towards the shoulder. From the perspective of the telescope, the distal Common Bile Duct appears continuous with the cystic duct and can easily be mistakenly identified as a long cystic duct. European instruction stresses the lateral retraction depicted in Figure 2 Such retraction places the cystic duct at right angles to the CBD,reducing the likelihood of misidentification.
2.	Meticulous dissection Arguably the most important step in preventing CBD injury. No clip should be placed on, and no incision should be made in, any structure until the transition between cystic duct and gallbladder infundibulum is clearly visualized.. Safe dissection absolutely requires that the cystic duct must be seen widening into the gallbladder before one can certify accurate anatomicidentification.
3.	Know the indications for intraoperative cholangiogram (IOC) If the patient is morbidly obese, has a significant prior history of disease or surgery in their abdomen, or if the surgical field is difficult to see due to the patient's anatomy or internal bleeding, the surgeon can always attempt an IOC.
	The Australian study reported that the risk of bile duct injury was decreased by half if IOC was performed during lap. or open cholecystectomy. As case complexity increased ( e.g., severe inflammation around the gall bladder), obtaining an IOC decreased the risk of bile duct injury by eight-fold!..

1.	Intraoperative Management of bile duct injury depends upon surgeon experience. Roux-en-Y hepaticojejunostomy to the proximal common hepatic duct or to the bifurcation of the right and left hepatic duct is necessary.
2.	Postoperative Pain, fever, abdominal distention, and abnormal liver function tests are signs of bile leakage into the peritoneal cavity. Definition and drainage of the biliary tree requires an experienced interventional radiology team that can perform complex biliary tree manipulation. Percutaneous transhepatic cholangiography and percutaneous biliary drainage can delineate any biliary defect, and will divert the bile away from the area by allowing it to drain. The best diagnostic modality to demonstrate this bile leak is a Pipida (P-isopropylacetanilide-iminodiacetic acid) Scintigram (99% accuracy). These leaks are best managed by the placement of a common bile duct stent via ERC. via gravity into a bile bag.

Control of bile peritonitis often means creating drainage for a biloma in the region of the biliary defect. Reconstruction of the biliary tree usually means construction of a hepaticojejunostomy in an elective setting. A wait of 4-6 weeks allows most peritonitis to settle, improving the likelihood of a good repair.

BLEEDING COMPLICATIONS
The most common bleeding problems relate to improper insufflation techniques (iliac or aortic injury), poor selection of abdominal wall puncture sites (epigastric vessel injury), failure to visualize the trocar sites upon withdrawal of the laparoscopic sleeves at completion of the procedure, unfamiliarity with the vascular anatomy of the procedure being performed, inadequate laparoscopic training in the use of hemostatic techniques available, and undiagnosed coagulopathy . Bleeding can occur during the dissection – from the abdominal wall, from the liver bed or from hemostatic clips coming off after the surgery. It can usually be controlled endoscopically; if bleeding cannot be controlled, the procedure will be terminated and the abdomen opened to gain direct control.

The bleeding and duct-injury rates with the open procedure are reported at about 0.4%, whereas they run almost 1 % with the laparoscopic procedure.
Non-biliary complications can be equally devastating, but have received less attention in literature. They occur as frequently as biliary injuries, and can be life-threatening and difficult to manage.

Perforation
Perforation of the bowel during laparoscopy can occur either by puncturing the bowel with the trocars used to enter the abdomen or by the dissecting instruments used during the procedure. Patients with a perforation require an emergency operation(s) to repair the injury. The commonest is duodenal perforation during dissection of the Calot's triangle.

Dropped gallstones
There has been a considerable increase in the number of perforations of the gallbladder (10%-32%), resulting in intraperitoneal gallstone spillage. This spillage has caused an increase in the incidence of lost gallstones( 0.2t - 20%) Recently, Läuffer et al published a review of lost gallstones including many macroabscesses in different localizations, granulomas, fistulas, bowel obstruction, cholelithoptysis and cholelithorrhea, and migration of stones into the femoral canal, pelvis, and ovary. Previously, there had been reports about the elimination of biliary stones through the urinary tract as a late complication.

Reference