الفهرس 
Aim of the workOnly 14 pages are availabe for public view
 |  | from | 209 |  |  |
| | | from | 209 | | |
Abstract
Summary
Over the last two decades, laparoscopic cholecystectomy
(LC) has gained worldwide acceptance and considered to be
as ”gold standard” in the surgical management of
symptomatic calcular cholecystitis.
Most major bile duct injuries are as a result of
misidentification of ductal structures. Technical
complications, such as thermal injury, tenting of the ducts,
and dissecting too deeply, are less frequent causes of bile
duct injuries. Surgeons’ inexperience, acute inflammation,
cystic duct impaction, excessive bleeding, and aberrant
anatomy are all risk factors for bile duct injuries
Approximately 75% of patients with bile duct injuries will
have a delayed presentation ranging from days to months, the
variety of imaging options for the postcholecystectomy
patient who presents with pain, fever, or jaundice; ultrasound
and computed tomography (CT) are both good modalities for
assessing fluid collections and bile duct dilatation, and can
provide guidance for percutaneous drainage. A hepatobiliary
iminodiacetic acid (HIDA) scan can compliment the
evaluation by determining whether there is complete ductal
obstruction, leakage of bile, or both.
Summary
159
Understanding the anatomy of the gallbladder and the
extra hepatic biliary system is essential to all clinicians
caring for patients with hepatobiliary disorders. Biliary
anomalies are not uncommon and over 50% of all patients
undergoing a biliary tract procedure will have either a ductal
or an arterial anomaly. The failure to recognize such a
congenital problem can result in significant per operative
morbidity.
The liver, gallbladder and small intestine are
connected by a series of thin tubes called bile ducts. The bile
ducts are part of the digestive system. The bile ducts and
gallbladder are also part of the biliary system, or biliary tract.
The extrahepatic biliary tract is a closed system
designed to collect, store, and concentrate bile secreted by
the liver and that is intermittently delivered to the duodenum
through the bile ducts. Bile contains bile salts, a key
component involved in the digestion and absorption of fats
and liposolubles vitamins.
The motor functions of the biliary tract are integrated
with the rest of the gastrointestinal tract in the fasting and
digestive periods through complex neurohormonal
mechanisms that include the vagus and splanchnic nerves
and the hormone CCK as the major actors.
Summary
160
Laparoscopic surgery is a modern surgical technique in
which operations are performed far from their location
through small incisions (usually 0.5–1.5 cm) elsewhere in the
body. Also called minimally invasive surgery (MIS) bandaid
surgery or keyhole surgery.
Bile duct injury (BDI) has long been recognized as
serious complication of cholecystectomy and its occurrence
has been highlighted with introduction of laparoscopic
surgery. Injury to the biliary tree is reported in
approximately 0.2% of patients undergoing open
cholecystectomy
The precise rate of BDI in laparoscopic era is however,
difficult to determine. A recent study from the west of
Scotland does suggest that the bile duct injury rate had fallen
from 0.8% to 0.4% in recent years
It was found that the fibrosis in the triangle of Calot, acute
cholecystitis, obesity, local hemorrhage, variant anatomy and
fat in the portahepatis were identified as risk factors
Undoubtedly, surgical experience is a significant risk
factor in the occurrence of bile duct injuries with the
incidence appearing to fall as lap. expertise increases
In Bithmus classification scheme, five strictures type are
recognized, reflecting the location with respect to the hepatic
Summary
161
duct confluence (Types 1-2-3-4) or involvement of an
aberrant right sectoral hepatic duct with or without a
concomitant hepatic duct stricture type
Prevention of the injury through education and
attention to anatomy is the most effective form of prevention.
Prevention of biliary injury by continuing to emphasize safe
technical aspects of the procedure during residency training,
by continuing to evaluate our results in practice, and by
promoting ongoing education programs such as this forum to
help surgeons achieve this goal. Complications that we see
currently are no longer a result of a learning curve experience
Epidemiologists classify prevention of health problems
into primary and secondary. Primary prevention involves
steps aimed at limiting the incidence of disease/complication
by controlling causes and risk factors. Secondary prevention
aims at early detection of the problem and its prompt and
effective management.
The technical considerations for safely performing
laparoscopic cholecystectomy include proper anatomic
dissection and the risks of instrument malfunction. Some risk
factors include operation on the acutely inflamed gallbladder,
thermal injury to the bile duct, and tenting injuries
The management of bile duct injuries generally is best
performed in major medical centers by experienced
Summary
162
multidisciplinary teams. This multidisciplinary approach and
improved surgical experience have led to a significant
improvement in the short-term results from the treatment of
these patients.
Most patients with a bile duct injury after laparoscopic
cholecystectomy present during the very early postoperative
period in one of two ways. Some patients present with biliary
obstruction, manifested as progressive elevation of liver
function test levels, particularly total bilirubin and alkaline
phosphatase levels. These changes often can be seen as early
as postoperative day 2 or 3
Not all late biliary injuries require intervention. Some
patients may remain entirely asymptomatic, the injury being
diagnosed by a coincidental abdominal ultrasound or blood
test showing elevated liver function. Unneeded intervention
in such asymptomatic patients may not be necessary or
desirabl