Voluntary and involuntary ligature of the bile duct in iatrogenic injuries: a nonadvisable approach.
BACKGROUND
Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation." Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury.


METHODS
We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed.


RESULTS
A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed.


CONCLUSIONS
Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.
Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico, Mexico DF, Mexico. mamercado@quetzal.innsz.mx
Miguel Angel
MA
Mercado
Carlos
C
Chan
Juan Carlos
JC
Jacinto
Norberto
N
Sanchez
Alexandra
A
Barajas
D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D001652:Bile Ducts / Q000293:injuries*; D049448:Cholangiopancreatography, Magnetic Resonance; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006500:Hepatic Duct, Common / Q000601:surgery; D006801:Humans; D007049:Iatrogenic Disease; D007431:Intraoperative Complications; D007583:Jejunum / Q000601:surgery; D008026:Ligation / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors