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

Ankit Gupta, Saurabh Agrawal, Namrata Sharma, Nakum Parth


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.


Laparoscopic cholecystectomy, Bile duct injury, Critical view of safety, Operative grading system for cholecystitis severity

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Sahu SK, Agrawal A, Sachan PK. Intra-operative Difficulties in Laparoscopic Cholecystectomy. Jurnalul de Chirurgie. 2013;2:149-55.

Choudhry NK, Wright JG, Singer PA. Outcome rates for individual surgeons: concerns about accuracy, completeness, and consequences of disclosure. Surgery. 1994;115:406-8.

Russell EM, Bruce J, Krukowski ZH. Systematic review of the quality of surgical mortality monitoring. Br J of Surg. 2003;90:527-32.

Martin RCG, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg. 2002;235:803-13.

Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes. J Am Coll Surg. 2004;198:626-32.

Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001;13:475-80.

The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324:1073-8.

Windsor JA, Pong J. Laparoscopic biliary injury: more than a learning curve problem. Aust N Z J Surg. 1998;68:186-9.

Calvete J, Sabater L, Camps B. Bile duct injury during laparoscopic cholecystectomy: myth or reality of the learning curve. Surg Endosc. 2000;14:608-11.

Sodergren M, Espina OF, Clark J, Teare J, Yang G. Evaluation of orientation strategies in laparoscopic cholecystectomy. Annals Surg. 2010;252:1027-36.

Kanakala V, Borowski DW, Pellen MG, Dronamraju SS, Woodcock SA. Risk factors in laparoscopic cholecystectomy: a multivariate analysis. Int J Surg. 2011;9:318-23.

Bouasker I, Ouaer EMA, Smaali I, Khalfallah M, Achour BJ. Laparascopic cholecystectomy on a previously operated abdomen. Tunis Med. 2010;88:88-91.

Sanford DE, Strasberg SM. A simple effective method for generation of a permanent record of the Critical View of Safety during laparoscopic cholecystectomy by intraoperative ‘doublet’ photography. J Am Coll Surg. 2014;218:170-8.

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101-25.

Sugrue M, Sahebally SM, Ansaloni L, Zielinski MD. Grading operative findings at laparoscopic cholecystectomy: a new scoring system. World J Emergency Surg WJES. 2015;10:14.

Langenbuch CJA. Ein Fall von Extirpation Gallenblase wegen chronischer Cholelithiasis: Heilung. Berl Klin Wochenschr. 1882;19:725-7.

Mouret P. From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: the prospective future. Dig Surg. 1991;8:124.

Huang ZQ, Huang XQ. Changing patterns of traumatic bile duct injuries: A review of forty years’ experience. World J Gastroenterol. 2002;8:5-12.

Moore MJ, Bennett CL. The learning curve for laparoscopic cholecystectomy: The Southern Surgeons Club. Am Surg. 1995;170:55-9.

Fullarton GM, Bell G. Prospective audit of the introduction of laparoscopic cholecystectomy in the west of Scotland; West of Scotland Laparoscopic Cholecystectomy Audit Group. Gut. 1994;35:1121-6.

Richardson MC, Bell G, Fullarton GM. The West of Scotland Laparoscopic Cholecystectomy Audit Group; Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. Br Surg. 1996;83:1356-60.

Schlumpf R, Klot HP, Wehrli H, Herog U. A nation’s experience in laparoscopic cholecystectomy; prospective multicenter analysis of 3722 cases. Surg Endosc. 1994;8:35-4l.

Z'graggen K, Wehrli H, Metzger A. Swiss Association of Laparoscopic and Thoracoscopic Surgery; complications of laparoscopic surgery in Switzerland: a prospective 3 years study of 10, 174 patients. Surg Endosc. 1998;12:1303-10.

Waheeb R. Bile Duct Injuries Following Laparoscopic Cholecystectomy: A Clinical Study. Al-Kubati Saudi J Gastroenterol. 2010;16(2):100-4.

Russell JC, Walsh SJ, Mattie AS, Lynch JT. Bile duct injuries, 1989-1993. A state wide experience; Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg. 1996;131:382-8.

Asbun HJ, Rossi RL, Lowell JA, Munson JL. Bile duct injury during laparoscopic cholecystectomy: Mechanism of injury, prevention, and management. World J Surg. 1993;17:547-52.

Pisano M, Ceresoli M, Campanati L, Coccolini F, Falcone C, Capponi MG, et al. Should We must push for primary surgery attempt in case of acute cholecystitis? A retrospective analysis and a proposal of an evidence based clinical pathway. Emergency Med. 2014;4:201.

Kumar N. Assessment of Degree of Difficulty in Laparoscopic Cholecystectomy using Intraoperative Scoring System. J Clin Diagnostic Res. 2017;11.

Pucher PH, Brunt LM, Fanelli RD. SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy. Surg Endosc. 2015;29:3074-85.

Barot TC, Canales A, Irving J. SAGES 6 steps Protocol for minimizing bile duct Injuries: a single center experience. SAGES 2016. Available at:

Nijssen MA, Schreinemakers JM, Meyer Z. Complications after laparoscopic cholecystectomy: A video evaluation study of whether the critical view of safety was reached. World J Surg. 2015;39:1798-803.

Tornqvist B, Stromberg C, Persson G. Effect of intended intra-operative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population-based cohort study. BMJ. 2012;345:6457.

Sheffield KM, Riall TS, Han Y. Intra-operative cholangiography during cholecystectomy. JAMA. 2013;310:812-20.

Gharaibeh KI, Ammari F, Heiss AH, Jaberi ATM, Qasaimeh GR, Hani BK, et al. Laparoscopic cholecystectomy for gallstones. Ann Saudi Med. 2001;21:312-6.

Morgenstern L, Berci G, Pasternak EH. Bile leak after biliary tract surgery: a laparoscopic perspective. Surg Endosc. 1993;7:432-8.

Balija M, Huis M, Szerda F, Bubnjar J, Stulhofer M. Laparoscopic cholecystectomy accessory bile ducts. Acta Med Croatica. 2003;57:105-9.

Lien HH, Huang CS, Shi MY, Chen DF, Wang NY, Tai FC, et al. Management of bile leakage after laparoscopic cholecystectomy based on etiological classification. Surg Today. 2004;34:326-30.