Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Human liver organoid derived intra-hepatic bile duct cells support SARS-CoV-2 infection and replication and its comparison with SARS-CoV

BackgroundAlthough the main route of infection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the respiratory tract, liver injury is also commonly seen in many patients, as evidenced by deranged parenchymal liver enzymes. Furthermore, patients with severe liver disease have been shown to have higher mortality. Overall, the mechanism behind the liver injury remains unclear.Approach and resultsWe showed that intra-hepatic bile duct cells could be grown using a human liver organoid platform. The cholangiocytes were not only susceptible to SARS-CoV-2 infection, they also supported efficient viral replication. We also showed that SARS-CoV-2 replication was much higher than SARS-CoV.ConclusionOur findings suggested direct cytopathic viral damage being a mechanism for SARS-CoV-2 liver injury.

Extraluminal recanalization for postoperative biliary obstruction using transseptal needle

Background Postoperative biliary strictures are commonly related to accidental bile duct injuries or occur at the site of biliary anastomosis. The first-line treatment for benign biliary strictures is endoscopic therapy, which is less invasive and repeatable. However, recanalization for biliary complete obstruction is technically challenging to treat. The present report describes a successful case of treatment by extraluminal recanalization for postoperative biliary obstruction using a transseptal needle. Case presentation A 66-year-old woman had undergone caudal lobectomy for the treatment of hepatocellular carcinoma. The posterior segmental branch of the bile duct was injured and repaired intraoperatively. Three months after the surgery, the patient had developed biliary leakage from the right hepatic bile duct, resulting in complete biliary obstruction. Since intraluminal recanalization with conventional endoscopic and percutaneous approaches with a guidewire failed, extraluminal recanalization using a transseptal needle with an internal lumen via percutaneous approach was performed under fluoroscopic guidance. The left lateral inferior segmental duct was punctured, and an 8-F transseptal sheath was introduced into the ostium of right hepatic duct. A transseptal needle was advanced, and the right hepatic duct was punctured by targeting an inflated balloon that was placed at the end of the obstructed right hepatic bile duct. After confirming successful puncture using contrast agent injected through the internal lumen of the needle, a 0.014-in. guidewire was advanced into the right hepatic duct. Finally, an 8.5-F internal–external biliary drainage tube was successfully placed without complications. One month after the procedure, the drainage tube was replaced with a 10.2-F drainage tube to dilate the created tract. Subsequent endoscopic internalization was performed 5 months after the procedure. At the 1-year follow-up examination, there was no sign of biliary obstruction and recurrence of hepatocellular carcinoma. Conclusions Recanalization using a transseptal needle can be an alternative technique for rigid biliary obstruction when conventional techniques fail.

Extra hepatic bile duct injury after laparoscopic cholecystectomy: a retrospective study

Background: Laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedure among the basic surgeries. Incidence of common bile duct (CBD) injury as high as 1.4-3% has been reported in some studies. The aim of this study was to estimate the incidence and predictors of CBD injury who underwent elective laparoscopic cholecystectomy.Methods: A retrospective observational study conducted at Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh India. Data was collected for a period of 1 year between March 2019 till 2020.Results: In majority of laparoscopic cholecystectomy we encountered moderate degree of difficulty. Extra hepatic bile duct injuries occurred in 1.4% of cases and were classified according to Strasberg classification. Type A injury was most common followed by type E2. Most major bile duct injuries were recognized intraoperatively. No mortality was noted in our study.Conclusions: Bile duct injuries is a major complication of laparoscopic cholecystectomy with significant morbidity and mortality, reduced survival impaired quality of life and subsequent litigations. Majority of bile duct injuries, results mainly from the surgeon’s inexperience, misinterpretation of anatomy and poor surgical techniques.

Choledochogastric Fistula after Recurrent Acute Cholangitis Post-Cholecystectomy

This is a case of a 46 years old male presented with acute cholangitis 2 years after laparoscopic cholecystectomy for cholecystolithiasis. He underwent biliary drainage and common bile duct (CBD) exploration for multiple stones at 2017. A year later, he presented with a recurrent acute cholangitis associated with choledocholithiasis and dilatation of left hepatic bile duct. Cholangiogram revealed that there is contract flowing to the stomach from the CBD, showing a choledochogastric fistula. Exploratory laparotomy was performed with CBD exploration with extraction of multiple stones, choledochoscopy and hepatojejunostomy. Insertion of PTC drain over a guidewire passed through a fistulous opening into the stomach. We decided on conservative management for fistula tract to heal.