Surgical Accidents
Evaluating the Laparoscopic Cholecystectomy Case (continued)

In contrast to the classic case of transection described above, one can encounter cases involving the failure of a ligature placed over a properly identified cystic duct remnant. While faulty surgical technique may well have caused such a failure, the proof of error is often difficult. Additionally, such an error does not usually produce grave consequences.

One should also be aware that bile can leak even if the bile duct has not been violated because removal of the gallbladder exposes tiny accessory bile ducts that leak. This condition is readily treated. Finally, the presence of bile stones can also cause injuries to the common bile duct. Removing stones lodged within a bile duct can also cause injury to a duct, resulting in the sloughing of tissue and bile leakage. One should also be aware that the classic lap-chole case is not by any means the sole meritorious case arising in the setting of a laparoscopic cholecystectomy. Inadvertent perforation of the bowel at the time of trocar placement is but one example of a meritorious case. One would be well advised to consult chapter 16 of SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACK, 257-78 (George D. Zuidema, M.D. ed., 4th ed. 1996), for an extensive and comprehensive description of classic and other complications of cholecystectomy and how those complications can be prevented.

For the classic meritorious lap-chole case, the surgeon fails to discover the complete transection of the bile duct at the time of the operation, most often because the surgeon misidentifies the cystic duct. The surgeon, thinking the cystic duct is at hand, observes an angle between the apparent cystic duct and another duct-like structure. The surgeon then presumes that this angle represents the juncture of the cystic duct and the common bile duct, failing to recognize that the angle is instead caused by tension the surgeon is placing upon the gallbladder. The error is not in producing the angular distortion of the common duct; rather, the surgeon errs by failing to identify with certainty the structure about to be ligated or divided before dividing the structure. If the common bile duct is erroneously divided, the surgeon, believing that the gallbladder and cystic duct remnants have been liberated, will remove them, but in so doing, will tear the common hepatic duct or right and/or left hepatic ducts by removing the gallbladder. Where the common duct has been divided instead of the cystic duct, the cystic duct remains intact attached to the common bile duct and higher biliary radicals.

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