Bile Duct Injury
This really is considered the most important and serious complication because of long term effect on the liver performance. Preliminary higher occurrence of Common Bile Duct accidents have finally come down to the amount seen in open up surgical era. The particular damage can be a perforation or horizontal rip of theCommon Bile Duct wall. Partial or total cutting from the duct, application of solitary or several clips across the duct, cautery burn from the duct, and surgical excision from the Common Bile Duct. The level of trauma could be in the supra duodenal portion to the porta hepatis level. Bismuth’s classification is put on the particular bile duct damage. Bile duct injury results in extravasation of bile to the peritoneal cavity. This causes chemical peritonitis. Bile leads to thrombosis of arteries across the Common Bile Duct leading to ischemic necrosis. Bile is an excellent culture moderate for bacteria. Therefore the urgent need to drain the extravasated bile to avoid oncoming of infection esp. by gram negative organism. Common Bile Duct exploration by any method boosts the chance of biliary leak.
Bile may extravasate with out injury to the Common Bile Duct. Within clip failure over the cystic duct, bile flows into the peritoneal cavity. Congenital abnormalities of the biliary system eg. Duct of Lushka, low medial insertion of cystic duct, low insertion of cystic duct, duplicated GB with two cystic ducts are known causes of biliary ductal injury and leak without injury to Common Bile Duct.
Not many surgeons drain the GB bed routinely. During these patients the first indication associated with biliary extravasation is the drainage of bile. As majority don't drain the peritoneal cavity, the very first indication of the problem clinically is that the patient doesn't feel great, isn't active and develops tachycardia. Clinical suspicion requires urgent evaluation. US will detect fluid accumulation within the peritoneal cavity as well as determines the quantum of fluid accumulated and whether it is loculated or not. Once fluid accumulation is made, it must be drained at the earliest. Initially a percutaneous aspiration under US guidance is performed. This confirms the existence of bile. If there is re accumulation of bile, bile duct injury is confirmed. Continuous drainage is to be instituted. This can be done by per cutaneous US guided catheter drainage or by laparoscopic technique. The second offers the advantage of undertaking peritoneal lavage and possible management from the lesion. It ought to be emphasised that primary repair ought to be carried out inside a high quantity centre specialising in hepato-biliary surgery. Attempts of repair by inexperienced surgeons do more damage to the structures and to the individual over time.
Further evaluation is needed for determining the amount and nature from the damage. Numerous non invasive methods like CT, MRI, 3D Doppler, and scintigraphy are available. Correct anatomical evaluation is acquired by carrying out Endoscopic Retrograde Cholangiography. ERC not just localises the amount of the lesion, extent of the lesion and also the probable cause, it provides the chance to attempt therapeutic procedure - stenting of the Common Bile Duct.
Endo therapy entails passing of guide across the site of injury, dilating the narrowed area with balloon or rigid dilators and positioning stent over the pathological area to enable the bile in the proximal biliary segment to empty to the duodenum. The lesions that can be successfully managed by ERC are leak from cystic duct, punctures or lateral tears of CBD and partial clipping from the duct.
When ERC methods don't succeed or even lesion is not amenable to endo therapy, surgical repair needs to be completed. The aim of surgery would be to restore the passage of bile to the alimentary tract. As mentioned this should be completed by an experienced hepato biliary surgeon in a high volume centre. The principle is to anastamose the biliary radicals into an isolated segment of small bowel to be able to prevent ascending infection into biliary system resulting in cholangitis [bilio enteric]. The procedure becomes relatively simple if there is a segment of common hepatic duct. Other wise dissection has to be extended into the hilar plate to identify all the biliary radicals for anastamosis to jejunum, thereby provide drainage of all the hepatic segments.
Late complications of bile duct injury are biliary cirrhosis, portal hypertension and it is complications ending in liver failure. Cholecystectomy accomplished for benign stone disease should not create a ‘biliary cripple’ patient.
Immediate post operative bleed indicates failure of primary haemostasis, eg. Slipped clip across the artery. Venous bleed occurs when the intra abdominal pressure is reduced. Injury may occur to right hepatic artery.
Clinical options that come with fall of BP, tachycardia, pallor, presence of fresh blood thro the drainage tube confirms the intra peritoneal bleed. Immediate exploration by open or laparoscopic approach is mandatory. Bleeding point is identified and haemostasis obtained. Site of arterial bleed is from cystic artery or from small aberrant vessel. Venous bleed is from the GB bed or from the dilated veins in portal hypertension. If these sites are dry, search for port site bleeder. When there is large assortment of blood within the peritoneal cavity it is advisable to open the abdomen and employ Pringle manoeuvre to acquire quick charge of the bleed.
Postponed bleed or secondary bleed follows localized infection resulting in vascular erosion. Bigger vessel is included leading to massive loss of blood with high morbidity and mortality. Rarely coagulation defect can set in cirrhotic liver due to decompensation of liver function.
First part and genu from the duodenum would be the commonest areas of injury. The dissection of densely adherent GB from the duodenum can result in immediate perforation. Late duodenal wall necrosis occurs because of cautery burn. Small intestine and colon can get perforated during the exchange and passage of instruments particularly when they aren't visually monitored during the introduction. These injuries aren't recognised at surgery. Patient develops classical feature of peritonitis within 48 hrs.
Injuries associated with instrument use.
The actual grasper keeping the particular fundus of the GB may slip and penetrate the diaphragm leading to pneumothorax, haemo thorax, haemo pericardium, or perforation of myocardium. The below surface of liver could be traumatised. Accidental entry from the instrument into major blood vessel - portal vein, IVC, will result in catastrophe.
Utilization of mono polar electro cautery leads to warming up from the tip of the instrument. If this comes in contact with bowel, blood vessel etc. delayed coagulation necrosis occurs. Hence minimal utilization of mono polar cautery is advised. Similarly the harmonic scalpel tip gets heated and can cause unexpected tissue damage. Mono polar cautery will be replaced by bipolar cautery wherein the tissue heating is not dissipated towards the surrounding structures.
Complications peculiar to Pneumo peritoneum
Sub cutaneous emphysema at port site, mediastinum and neck may be noticed at the conclusion of surgery. Pneumo thorax, extensive emphysema can complicate prolonged surgical procedures or by accidental increase in the intra abdominal pressure during surgery. The infiltration of air into the mesentery of bowel can result in paralytic ileus. Delayed air embolism has been reported, site of entry of air thro an open vein which remained closed throughout the surgery due to raised intra abdominal pressure. Hypercapnia which occurs after prolonged surgery causes hypertension and cardiac irregularities.
When the gallbladder consists of multiple small stones and also the cystic duct is wide, likelihood of stones slipping into Common Bile Duct is high. This may trigger post operative obstructive jaundice, cholangitis, and acute biliary pancreatitis. Obstructed Common Bile Duct, leads to elevated biliary stress with chance of clip over the cystic duct giving way, leading to biliary peritonit is and biliary fistula. In just about all instances the stones can be removed by ERC, sphincterotomy, and basketting. Other available choices are ESWL, percutaneous trans-hepatic approach, or thro T tube tract if present.
Intra peritoneal spillage of stones generally passes away without problem. In few cases, it makes its way through the port site, umbilicus most commonly. From time to time through vault of vagina, rectal wall or abdominal wall leading to localised abscess, when drained discharges gall stones. This is discomforting towards the patient.
Port Site Hernia
This happens because of defective closure of port sites, esp. in obese patients particularly in the umbilical port.
Complications pertaining to Drainage and T tubes
T tubes are usually kept for 6-8 weeks. Due to digestive action, prolonged contact with bile the tube can get disintegrated and obtain avulsed in the junction from the stem of T and the intra biliary part .It can could be extracted by ERC.
Post Cholecystectomy Syndrome
Persistence of symptoms following cholecystectomy continues to be studied extensively. Many factors were regarded as cause of persistence of symptoms. Presences of long cystic duct remnant, stone in remnant cystic duct, incomplete or subtotal cholecystectomy were blamed. Additionally it's due to initial wrong diagnosis. Hiatus hernia and diverticular disease of colon being the common culprits.
Air Entrapment Syndrome
Deflation of pneumoperitoneum after surgery may fail to express the environment from pockets within the peritoneal cavity leading to abdominal distension and ileus.
Complications related to General Anaesthesia
Of the numerous known complications one has to be wary of deep vein thrombosis and pulmonary embolism. On table mechanisms to avoid DVT should be followed by anti coagulation protocol in high risk patients within the post operative phase.