Carroll B J, Birth M, Phillips E H
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
Surg Endosc. 1998 Apr;12(4):310-3; discussion 314. doi: 10.1007/s004649900660.
Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries.
A total of 46 bile duct injuries were analyzed by review of medical records, cholangiograms, videotapes, and surgeon statements. All cases were involved in malpractice litigation.
All types of injuries were represented. There were 15 transections, 11 excisions, 6 lacerations, 8 clip impingements, 3 burns, 2 bile leaks, and 1 cystic duct leak. In all, 72% of these injuries occurred in elective cases in which there was no acute inflammation. Cholangiograms were performed in 16 cases, but they were misinterpreted in 11 of them. Injury type and severity was similar in patients with and without cholangiography. A total of 80% of these injuries were not detected at the initial surgery. The average delay in diagnosis was 10 days. Complications were worse in patients with delayed diagnosis. Primary surgeons had less successful outcomes from repairs than referral surgeons (27% versus 79%). In 86% of cases, litigation was resolved in favor of plaintiffs by settlement or verdicts. The average award was $214,000.
Factors that predispose to lawsuits include treatment failures in immediately recognized injuries, complications that result from delays in diagnosis, and misinterpretation of abnormal cholangiograms. Injury prevention can be improved by increased awareness of common mistakes,. Improved cholangiographic technique and interpretation should decrease injury severity, delays in diagnosis, and subsequent morbidity.
医源性胆总管损伤是腹腔镜胆囊切除术最严重的并发症。本研究的目的是提高对该问题的认识，并教育外科医生了解这些损伤的后果。
通过查阅病历、胆管造影、录像带和外科医生陈述，对46例胆管损伤进行了分析。所有病例均涉及医疗事故诉讼。
涵盖了所有类型的损伤。其中有15例横断伤、11例切除术、6例撕裂伤、8例夹子压迫伤、3例烧伤、2例胆漏和1例胆囊管漏。总体而言，72%的这些损伤发生在无急性炎症的择期手术病例中。16例进行了胆管造影，但其中11例被误判。有无胆管造影的患者其损伤类型和严重程度相似。这些损伤中共有80%在初次手术时未被发现。诊断的平均延迟时间为10天。延迟诊断的患者并发症更严重。主刀医生修复手术的成功率低于会诊医生（27%对79%）。在86%的病例中，诉讼通过和解或判决解决，原告胜诉。平均赔偿金额为21.4万美元。
引发诉讼的因素包括对立即识别的损伤治疗失败、诊断延迟导致的并发症以及胆管造影异常的误判。通过提高对常见错误的认识可以改善损伤预防。改进胆管造影技术和解读应能降低损伤严重程度、诊断延迟及后续发病率。
