REFERAT

CEDERA SALURAN EMPEDU PASCA LAPAROSKOPIK KOLESISTEKTOMI

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2.1

Laparaskopik Kolesistektomi
Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed
by laparoscopic techniques. Laparoscopic surgery also referred to as minimally
invasive surgery describes the performance of surgical procedures with the assistance of
a video camera and several thin instruments.
During a laparoscopic surgical procedure, small incisions of up to half an inch are
made and plastic tubes called ports are placed through these incisions. The camera and
the instruments are then introduced through the ports which allow access to the inside of
the patient. The camera transmits an image of the organs inside the abdomen onto a
television monitor.The surgeon is not able to see directly into the patient without the
traditional large incision. The video camera becomes a surgeons eyes in laparoscopy
surgery, since the surgeon uses the image from the video camera positioned inside the
patients body to perform the procedure.
Benefits of minimally invasive or laparoscopic procedures include less post
operative discomfort since the incisions are much smaller, quicker recovery times, shorter
hospital stays, earlier return to full activities and much smaller scars. Furthermore, there
may be less internal scarring when the procedures are performed in a minimally invasive
fashion compared to standard open surgery. (USC)

2.2

Indikasi

2.3

Komplikasi
There are risks and complications with this procedure. They include but are not
limited to the following. General risks:

Infection can occur, requiring antibiotics and further treatment.

Bleeding could occur and may require a return to the operating room. Bleeding is
more common if you have been taking blood thinning drugs such as Warfarin,
Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).

Small areas of the lung can collapse, increasing the risk of chest infection. This may

need antibiotics and physiotherapy.

Increased risk in obese people of wound infection, chest infection, heart and lung

complications, and thrombosis.

Heart attack or stroke could occur due to the strain on the heart.
Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot

may break
off and go to the lungs.
Death as a result of this procedure is possible.

Specific risks:

2.4

Damage to large blood vessels causing bleeding.

Damage to gut and/or bladder when the instruments are inserted.
Rarely, gas fed into the abdominal cavity can cause heart and breathing problems.
The laparoscope method may not work and the surgeon may need to do open

surgery.
Stones may be found outside the gall bladder.
Gallstones may spill from the gall bladder and be lost in the abdominal cavity.
Some stones may be left behind in the bile duct and may need further treatment.
Some of the clips or ties may come off.
Damage to the bile tubes.
The wound may not heal normally. The wound can thicken and turn red. A

weakness can happen in the wound with the development of a hernia (rupture).
Adhesions (bands of scar tissue) may form and cause bowel obstruction.
Symptoms experienced before surgery may persist after the surgery.
An allergic reaction to the injected Contrast is rare.

Cedera Saluran Empedu

Bile duct injury is perhaps the most feared complication of laparoscopic
cholecystectomy. The focus of this study was on the immediate and short-term outcome
of patients who have undergone repair of major bile duct injuries with respect to
hospital stay, perioperative interventions, and reoperations. (The consequences)
Many classification systems have been proposed to help standardize the
description, guide the treatment, and compare the outcomes of biliary injuries. However,
no single classification system is universally accepted as the standard. The earliest was
proposed by Bismuth and colleagues in 1982. It was designed to categorize strictures
according to its anatomic location. Type 1 lesions are low common hepatic duct lesions

with a hepatic duct stump greater than 2 cm. Type 2 lesions are proximal common hepatic
duct lesions with a hepatic duct stump less than 2 cm. Type 3 and 4 lesions are strictures
at or above the level of the left and right hepatic duct confluence. In type 3 lesions, both
sides of the duct are still patent and communicating, whereas in type 4 lesions, the ducts
are not communicating. Type 5 injuries describe involvement of an aberrant right sectoral
duct injury concomitant with a common hepatic duct stricture.45 The anatomic location
of these injuries guides the surgeon regarding which type of open repair is feasible and
appropriate to drain all sections of the liver. As laparoscopic cholecystectomies became
more popular, bile duct injuries became more complicated and more proximal. Strasberg
and colleagues8 proposed a classification system that encompassed injuries commonly
incurred during laparoscopic cholecystectomies. Instead of simply describing strictures it
included leaks, partial transections, and complete occlusions (Fig. 4). This classification
system maintained its usefulness in guiding the type of repair necessary. Since then,
many other classification systems have tried to improve on that of Strasberg by adding
subcategories to describe more types of injuries. The system proposed by Neuhaus and
colleagues separated out leaks from the cystic duct (A1) from leaks from the liver bed
(A2), separated strictures (E) versus complete obstruction (B), and subcategorized partial
(B1), complete (B2), and transactions (D) of common bile duct. These subcategories give
clearer descriptions of the injury but do not change much in terms of picking treatment
modalities. An advantage of newer classification systems such as the Stewart-Way and
the Hanover system is the classification of concomitant vascular injuries. Vascular
injuries can disrupt the blood supply to the bile duct and compromise the success of
biliary reconstruction. Stewart and Way40 proposed a system that groups injuries
according to anatomic pattern and causation. The system describes the close proximity of
the cystic artery and duct to the right hepatic artery and duct, which can result in
misidentification and injury. There are a few disadvantages of the Stewart-Way
classification: it does not describe lesions that occur late, such as strictures; it does not
classify transections at or above the bifurcation; and it does not classify injury to right
sectoral ducts. These disadvantages limit its use in planning right aberrant duct or high
bile duct repairs. The Hanover classification incorporates the detailed classification of
Neuhaus with its associated vascular injury; however, it can be overwhelming and

complex. Considering that most vascular injuries do not require repair, the authors use the
Strasberg classification system because it gives just enough description of the injury
relevant to their treatment modalities
2.4

Epidemiologi

2.5

Patofisiologi
There are several risk factors associated with bile duct injury, and these can be
characterized as patient factors, local factors, and extrinsic factors. Patient factors include
but are not limited to obesity, advanced age, male sex, and adhesion. Local factors
include severe inflammation and/or infection, aberrant anatomy, and hemorrhage.
Extrinsic factors include surgeons experience and properly functioning equipment. The
presence of any of these risk factors should alert the surgeon to the increased possibility
of encountering a potentially dangerous situation during laparoscopic cholecystectomy.
Even tired residents have been implicated as a risk factor by the suggestion that resident
work hour restrictions are a protective factor for bile duct injuries. The association of
decreased incidence of bile duct injury with the institution of work hour restrictions is
likely a correlation without causality.
Error analyses in large series of patients who have had bile duct injury have
shown that misidentification of the common bile duct, the common hepatic duct, or an
aberrant duct (usually on the right side) is the most common cause of bile duct injury.7
Because misidentification is the cause of most injuries, the goal of dissection should be
the conclusive identification of the cystic structures within the Calot triangle. If the cystic
duct and cystic artery are conclusively and correctly identified before dividing, more than
70% of bile duct injuries would be avoided. Misidentification, however, is not the only
cause. Technical failure such as slippage of clips placed on the cystic duct, inadvertent
thermal injury to the common bile duct, tenting of the common duct during clip
placement with subsequent stricture, and disruption of a bile duct entering directly into
the gallbladder fossa are other less common causes of injury.

2.6

Diagnosis
Recognition and proper diagnosis of bile duct injuries is advantageous in
preventing serious complications and obtaining high repair success rates.17 In 10% to
30% of the time, bile duct injuries are recognized at the time of surgery.18,19 Injuries are

suspected or diagnosed when a bile leak is visualized, seen during IOC, or realized after
further dissection to clarify the anatomy. Once recognized, the surgeon can assess its
severity and determine if there are any associated vascular injuries. Most surgeons have
the skill set to repair simple injuries such as cystic duct leak, gallbladder bed leak, and
partial duct lacerations. These injuries can be repaired immediately if the surgeon has the
expertise required.9 For more complex injuries, multiple studies have shown that an early
referral to a hepatobiliary surgeon with extensive experience in such injuries improves
prognosis.2022 A delay in referral leads to an increased complication rate after the
definitive repair, and a 1.5% mortality rate.2123 The success rate of first-time repairs of
a hepatobiliary surgeon was also found to be higher than that of the primary surgeon
(79% vs 27%).1,18 Despite these data, as much as 87% of repairs are still currently
performed by the primary surgeon. If the complex injury is incurred in an institution
without the capacity to treat these injuries, laparoscopic placement of a drain in the
surgical bed is preferred. Conversion to a laparotomy for diagnosis or drainage and/or
other endoscopic interventions is discouraged. Fischer and colleagues21 found that 49%
of interventions performed at the initial institution were inappropriate. Quick transfer to a
facility capable of and experienced in managing these injuries prevents delays in care and
decreases the need for reoperations. Unfortunately, most bile duct injuries are not
recognized intraoperatively, and most patients are sent home immediately after or within
24 hours. Patients who fail to recover within the first few days or develop progressive
vague abdominal symptoms should be evaluated for a bile duct injury. There are 2
general types of injuriesbiliary obstructions and bile leaksand sometimes both can
occur simultaneously. In addition to bile duct injury, concomitant vascular injuries are
often present, and resultant ischemia can complicate matters, especially if immediate
repair is performed and the vascular injury goes unrecognized. Obstructed patients
present with vague abdominal pain, anorexia, jaundice, and liver enzyme elevation.
Through an unknown mechanism, pneumoperitoneum itself can cause a transient liver
enzyme elevation and hyperbilirubinemia. Therefore, elevated laboratory values do not
predict complication after laparoscopic cholecystectomy. 2426 This transient increase
resolves after 1 week, but it may contribute to an average delay of 1 to 2 weeks in the
diagnosis.18 Obstructions secondary to biliary strictures appear weeks to months later

and may present as recurrent cholangitis, obstructive jaundice, or secondary biliary

cirrhosis.23 Because hepatic bile is isotonic in nature and contains lower concentrations
of bile salts than gallbladder bile, bile leaks do not cause extreme peritoneal irritation.
Patients often complain of vague symptoms, such as nonspecific abdominal fullness,
distension, nausea, vomiting, abdominal pain, fever, and chills. These symptoms may represent and lead to bilomas, biliary fistulas, cholangitis, sepsis, or multiorgan system
failure.23 To make the diagnosis more difficult, results of laboratory tests can be normal
or show only slight elevation in bile leaks. To improve prognosis and outcomes for bile
duct reconstruction, expedient evaluation of suspected bile duct injury is necessary. There
should be a low threshold for requesting necessary imaging studies.
2.7

Tatalaksana
Management depends on the timing of recognition of injury and the type, extent
and level of the injury. There is a growing body of literature supporting the importance of
early referral to a tertiary care hospital which can provide a multidisciplinary approach to
treat bile duct injury. Biliary reconstruction is best performed by a specialist surgeon.
Biliary anatomy should also be thoroughly investigated before any attempt at surgical
repair. Repair of a bile duct injury without defining the anatomy usually fails. Stewart and
Way reported only 4% and 31% success rate for repair of bile duct injury without prior
cholangiograms or incomplete cholangiographic evaluation of the entire biliary tree,
respectively.18 In contrast, the initial repair was successful in 84% of patients when the
cholangiograms were complete. The goal of surgical repair of the injured biliary tract is
restoration of a durable bile conduit, and prevention of short- and long-term
complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent
cholangitis and secondary biliary cirrhosis.
Management of injuries recognized during operation
Only 25%32.4% of injuries are recognized during operation,16,17,1922 which
is considered as the best time to perform repair. Immediate repair is most likely to
minimize the morbidity associated with the injury. If a bile duct injury is detected during
cholecystectomy, one should first call for help and consult an experienced hepatobiliary
surgeon. Intraoperative suspicion of bile duct injury should be followed by prompt
conversion to open laparotomy with cholangiography to determine if an injury is present

and to define the nature of the injury. If experienced surgeons in performing biliary
reconstruction are not available, one should carefully consider his own experience and
ability to repair the injury that is identifiable. Injudicious attempts at exploration of bile
leak by laparoscopic means or at open operation should be avoided as further extension
of the injuries into the intrahepatic ducts or subsequent damage to the arterial supply can
occur. Injuries are preferably repaired by an experienced hepatobiliary surgeon. In a
review of 88 patients with bile duct injury after laparoscopic surgery, only 17% of repairs
were successful in those performed by the primary surgeon compared with 94% of those
performed by a tertiary care biliary surgeon, and the hospital stay was three times longer
(222 days versus 78 days).18 The morbidity and mortality of those treated by a primary
surgeon compared with a tertiary care biliary surgeon was 58% and 1.6% versus 4% and
0%, respectively. These data are supported by another larger cohort study. Flum et al.
showed the adjusted hazard of death during follow-up was 11% greater if the repairing
surgeon was the same as the injuring surgeon.23 Heise et al. studied 175 patients with
bile duct injury and identified that the number of attempted repairs before referral was a
significant predictor of poor outcome.24 Therefore, for inexperienced surgeons,
subhepatic drains should be placed to prevent collection and if possible, external biliary
drainage should be performed to convert the bile duct injury into a controlled external
biliary fistula. The patient should then be referred to a specialized hepatobiliary unit.
Management of injuries recognized in the postoperative period
Initial management of patients with suspected bile duct injury in the postcholecystectomy period is directed at controlling sepsis, drainage of bilomas or
abscesses, establishing biliary drainage and establishing the diagnosis, type and extent of
the bile duct injury. Broad-spectrum parenteral antibiotics covering the common biliary
pathogens should be started. Intra-abdominal collection or abscess should be
percutaneously drained. Biliary drainage should be established. There is virtually no
indication to perform an urgent laparotomy, except for severe biliary peritonitis not
responding to percutaneous drainage. Biliary reconstruction in the presence of peritonitis
portends a statistically worse outcome in patients. Once sepsis is controlled, there is also
no rush to proceed with surgical reconstruction of the biliary tree. The inflammation, scar
formation and development of fibrosis take several weeks to subside. Attempts at repair

during this phase results in a high failure rate and a poor outcome. Reconstruction of the
biliary tract is best performed electively after an interval of at least 6 to 8 weeks.
1. Leaks from cystic duct stump or small ducts in liver bed
Bile leaks have been reported more commonly after laparoscopic than open
cholecystectomy and usually occurs as a result of injury to a minor duct that remains in
continuity with the CBD. The cystic duct stump and small peripheral right hepatic ducts
within the liver bed account for most injuries of this type. Cystic stump leaks can occur
from faulty clip application, slipping of the clips, necrosis of the cystic duct stump
proximal to the clip due to diathermy injury or cystic stump blow-out due to an
obstructing CBD stone. Endoscopic treatment by sphincterotomy and drainage by
insertion of a nasobiliary drain or internal biliary stent reduces the intraductal pressure
gradient maintained by the sphincter of Oddi, and diverts the bile flow away from the site
of leakage.2632 Endoscopic therapy by sphincterotomy, stenting or the combination is
effective in 80% 100% of patients with bile leaks.2632 However, there is no
comparative data to indicate the most effective approach. Only one randomized study in a
canine model showed biliary stenting significantly reduced the time to resolution of
cystic duct leaks as compared to sphincterotomy.33 For patients with intra-abdominal
fluid collections, percutaneous ultrasound-guided drainage of these collections should be
performed to avoid abdominal abscess formation. Most authors advocated biliary stent
insertion rather than sphincterotomy. In addition to reducing the intraducal pressure,
biliary stent also covers the leakage point and allows it to heal. The complications of
sphincterotomy can also be avoided. Nasobiliary tube placement avoids the need for a
second ERCP, but at the expense of disadvantages like accidental tube dislodgement,
patient discomfort and a longer hospital stay.
2. Partial CBD/CHD wall injuries
For partial defect in the duct, the best treatment option is primary closure with
fine absorbable sutures and subhepatic drainage. Partial transections of the bile duct may
also be primarily closed over a T-tube which exits the bile duct from a separate
choledochotomy. T-tube placement is still a controversial issue. There is no comparative
study on primary closure with or without a T-tube after bile duct injury. Partial defects
should be treated as complete ductal transection if the defect is large.

3. Complete CBD/CHD transection

End-to-end ductal repairs are rarely achievable without tension, even with
additional mobilization of the duodenum. A restricture rate of 100% has been reported for
end-to-end repair of laparoscopic bile duct injuries.18Atension-free Roux-en-Y
hepaticojejunostomy is the preferred procedure for the majority of major bile duct
injuries. For diathermy injury to the bile duct, the anastomosis should be made
proximally near to the confluence of the bile ducts to avoid stricture formation as a
consequence to coagulation injury to the collateral network of blood vessels supplying
the CBD/CHD.
4. Right/left hepatic duct or sectoral duct injuries
Right sectoral duct injury represents not only a diagnostic but also a therapeutic
challenge. The diagnosis is difficult in most cases due to the small size of the involved
ducts, and cholangiogram may be interpreted as normal. The key to management of an
isolated sectoral hepatic duct injury is recognition. Cholangiogram may not demonstrate
any bile leak and there is a normal confluence of the right and left hepatic ducts.
Recognition of absence of part of the right hepatic ductal system is the key to diagnosis.
Based on the cholangiogram, an interventional radiologist can access the involved hepatic
sector percutaneously by placing a percutaneous transhepatic biliary catheter into its
ductal system. External drainage allows prompt control of biliary leakage, eliminates
sepsis and allows optimal timing of elective biliary reconstruction. Surgical
reconstruction is performed to the isolated sectoral duct as a Roux-en-Y
hepaticojejunostomy. Lillemoe et al. reported nine patients with isolated right sectoral
ductal injury, seven of them following laparoscopic cholecystectomy, who were managed
by percutaneous drainage and Roux-en-Y hepaticojejunostomy to the isolated right
sector.34 In this series, all patients had undergone ERCP prior to referral with no
evidence of visible bile leak and were thought to have normal biliary anatomy. Six
(67%) of the nine patients had a long-term successful outcome with minimal or no
symptoms. In three patients, recurrent symptoms with pain and/or cholangitis developed
at a mean follow-up of 34 months. All three patients underwent PTC which demonstrated
an anastomotic stricture, and all were managed with percutaneous balloon dilation. After
a mean follow-up of 70.4 months, eight (89%) of these nine patients were asymptomatic.

If cholangiography demonstrates a major hepatic duct injury, reconstruction in the form

of a hepaticojejunostomy is required. Liver resection should be reserved for treatment
failures of surgical bypass.
5. Bile duct injuries associated with vascular injuries
The incidence of vascular injuries in patients with a postcholecystectomy biliary
injury is 16.7%47%,3540 the most frequent of which is the disruption of the right
branch of the hepatic artery because of the close proximity of the right hepatic artery to
the CHD. The right hepatic artery usually traverses posteriorly (80% to 90%) or
anteriorly (10% to 20%) to the duct. Unlike biliary injuries, it does not usually lead to
early significant complications and therefore probably remains unnoticed in most
patients. Hepatic artery ligation is usually tolerated without clinical sequelae owing to the
portal flow and the supply of arterial blood from collateral vessels. Controversy prevails
regarding the consequences and implications that the association of a bile duct injury and
an arterial injury may have. With regard to the impact of concomitant vascular injury to
the extrahepatic biliary tree, it has been reported that the presence of vascular injury is
associated with increased intraoperative bleeding during repair, more difficult
reconstruction and higher incidence of anastomotic stricture due to bile duct ischemia.
Liver atrophy or necrosis resulting from hepatic ischemia or secondary biliary cirrhosis
resulting from biliary stricture may need to be managed by liver resection or even
transplantation.4144 In the situation when this happens during cholecystectomy and
becomes promptly recognized, some authors suggested to try to repair the vascular injury
if possible.37,38 Others suggested arterial reconstruction when the distal right hepatic
artery can be exposed even during the delayed biliary reconstruction. 37,38 However,
other authors suggested not to attempt to reconstruct the injured artery and just to ignore
it regardless of the timing of recognition and/or repair, as the consequences of right
hepatic artery ligation in an otherwise healthy liver have been unremarkable.
2.8

Pencegahan

2.9

Prognosis

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