Iatrogenic bile duct injuries. The real incidence and contributing factors--implications for laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has achieved wide acceptance as the preferred treatment for symptomatic gallbladder disease. Yet there are alarming reports of iatrogenic bile duct injuries. To establish a comparison standard, the incidence of iatrogenic bile duct injury during conventional cholecystectomy has to be known. A single institutional retrospective review of 1,617 consecutive open cholecystectomies between 1980 and 1989 was performed. Eight patients (0.49%) sustained iatrogenic bile duct injury in this study. Inflammation, anatomic variation, or both were contributing factors in all injuries. Operative cholangiography identified the injury at the initial operation in three patients. Treatment consisted of either primary ductal repair, ductal repair over a stent, or ductal-enteric anastomosis. There were no late complications after surgery (follow-up 26 to 97 months; mean 50.9 months). The implications for laparoscopic cholecystectomy are apparent. Iatrogenic bile duct injuries are associated with acute inflammation and/or variant ductal anatomy; routine operative cholangiography assumes increased importance; and immediate repair of the injury minimizes long-term complications.