SAGES ANNUAL MEET, DALLAS,USA 2006
Complications of Surgery–P213
COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY TODAY- A REVIEW OF THE LITERATURE.- MANMOHAN VARMA MS, PRIVATE -
KANPUR, INDIA
OBJECTIVES: Laparoscopic cholecystectomy (LC) has emerged prominently in treatment of gallstone. Annually 770,000 procedures are performed
in USA alone. Complications have also changed. Thus it is prudent to review the literature on these complications. METHODS: Medline & PubMed
search was done for literature on the complications of LC till August 2005; its analysis is presented. RESULTS: Bile duct injury (BDI) is the scourge
of LC. Main cause is misperception & not lack of knowledge, skill or judgment. Misperception is so compelling that the problem is not recognized & is
an inherent risk of LC. Only 25% BDI are found peroperatively. Its incidence is 0.5% to 1.4% (few 2.7%). It is more severe & life-threatening. Mortality
& major morbidity after BDI were 12.1% & 30.3% respectively in a series of 13718 LCs. It has great impact on patient's physical & mental QOL. Some
need liver transplant. Beyond the learning curve, rate of BDI is still stable with significant legal & financial implications. But BDI is lesser at many
tertiary centers (0% in one). Nonbiliary damage is as frequent & devastating. Bleeding (mortality up to 0.2%) occurs from trocar sites or injury to
aorta, right hepatic artery (in 32% of BDI) & right external iliac artery. Stone spillage is 5% - 40% with problems in 7.0% like infection, abscess,
inflammation, adhesions, skin sinuses, bowel obstruction, pneumonia, cholelithoptysis, septicemia & middle colic vessel erosion. Added are bowel
injuries (up to 0.87%); diaphragmatic injury; portal vein injury; pseudoaneurysm of right hepatic artery; ilio-iliac arteriovenous fistula; liver laceration;
hemobilia; portal vein thrombosis; increased thromboembolism; large pneumothorax; huge surgical emphysema; clip migration led CBD stone; hernia
through falciform ligament defect with bowel obstruction; port site metastasis, TB & hernia. Pneumoperitoneum morbidity is up to 0.2%. Gas
embolism is rare & can kill. Anesthetic hazards need specific care. Limited information on litigations after LC favor surgeons in only 17.3%.
CONCLUSION: Complications of LC make it maximally invasive with only superficial small scars. Gallstone, a very common benign disease, does not
deserve risks of LC routinely. LC should be restricted to surgeons trained, experienced & working in tertiary hospitals. This would protect other
surgeons from lawsuits & undue stress of avoidable competition in surgical practice. Costs of LC's complications to healthcare system would reduce
too.
This paper, along with recent updates, has also been presented at 11th World Congress of Endoscopic Surgery, Yokohama, Japan 2008.
For Surgeons:
Bibliography of the above complications will be soon posted here to be available as ready reference. This can then be used
for defence in court of law since even most judges do not know that the laparoscopic surgeon's skill, experience and
judgment are usually not responsible for complications during Laparoscopic cholecystectomy.
This SINGLE HOLE SURGERY has been designed to protect the patients against the possibilities of these complications of 4 hole
surgery (LC) while giving them the advantages of minimally invasive surgery. It also is advantageous for surgeons as they shall not
be overburdened by:
1. Inherent and unpredictable complications of a procedure
2. Complications not detectable during surgery - as in many cases of bile duct injury.
3. Malpractice issues - Consumer Forum litigations, as patient thinks that if there is a complication in 4 hole surgery it is always the
neglect of the surgeon.
Complications of Surgery–P213
COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY TODAY- A REVIEW OF THE LITERATURE.- MANMOHAN VARMA MS, PRIVATE -
KANPUR, INDIA
OBJECTIVES: Laparoscopic cholecystectomy (LC) has emerged prominently in treatment of gallstone. Annually 770,000 procedures are performed
in USA alone. Complications have also changed. Thus it is prudent to review the literature on these complications. METHODS: Medline & PubMed
search was done for literature on the complications of LC till August 2005; its analysis is presented. RESULTS: Bile duct injury (BDI) is the scourge
of LC. Main cause is misperception & not lack of knowledge, skill or judgment. Misperception is so compelling that the problem is not recognized & is
an inherent risk of LC. Only 25% BDI are found peroperatively. Its incidence is 0.5% to 1.4% (few 2.7%). It is more severe & life-threatening. Mortality
& major morbidity after BDI were 12.1% & 30.3% respectively in a series of 13718 LCs. It has great impact on patient's physical & mental QOL. Some
need liver transplant. Beyond the learning curve, rate of BDI is still stable with significant legal & financial implications. But BDI is lesser at many
tertiary centers (0% in one). Nonbiliary damage is as frequent & devastating. Bleeding (mortality up to 0.2%) occurs from trocar sites or injury to
aorta, right hepatic artery (in 32% of BDI) & right external iliac artery. Stone spillage is 5% - 40% with problems in 7.0% like infection, abscess,
inflammation, adhesions, skin sinuses, bowel obstruction, pneumonia, cholelithoptysis, septicemia & middle colic vessel erosion. Added are bowel
injuries (up to 0.87%); diaphragmatic injury; portal vein injury; pseudoaneurysm of right hepatic artery; ilio-iliac arteriovenous fistula; liver laceration;
hemobilia; portal vein thrombosis; increased thromboembolism; large pneumothorax; huge surgical emphysema; clip migration led CBD stone; hernia
through falciform ligament defect with bowel obstruction; port site metastasis, TB & hernia. Pneumoperitoneum morbidity is up to 0.2%. Gas
embolism is rare & can kill. Anesthetic hazards need specific care. Limited information on litigations after LC favor surgeons in only 17.3%.
CONCLUSION: Complications of LC make it maximally invasive with only superficial small scars. Gallstone, a very common benign disease, does not
deserve risks of LC routinely. LC should be restricted to surgeons trained, experienced & working in tertiary hospitals. This would protect other
surgeons from lawsuits & undue stress of avoidable competition in surgical practice. Costs of LC's complications to healthcare system would reduce
too.
This paper, along with recent updates, has also been presented at 11th World Congress of Endoscopic Surgery, Yokohama, Japan 2008.
For Surgeons:
Bibliography of the above complications will be soon posted here to be available as ready reference. This can then be used
for defence in court of law since even most judges do not know that the laparoscopic surgeon's skill, experience and
judgment are usually not responsible for complications during Laparoscopic cholecystectomy.
This SINGLE HOLE SURGERY has been designed to protect the patients against the possibilities of these complications of 4 hole
surgery (LC) while giving them the advantages of minimally invasive surgery. It also is advantageous for surgeons as they shall not
be overburdened by:
1. Inherent and unpredictable complications of a procedure
2. Complications not detectable during surgery - as in many cases of bile duct injury.
3. Malpractice issues - Consumer Forum litigations, as patient thinks that if there is a complication in 4 hole surgery it is always the
neglect of the surgeon.
 | |  | |  | |  | |  | |  | |  |
| SINGLE HOLE SURGERY FOR GALL BLADDER STONE |
1. Gall Bladder Stone is a benign disease - meaning thereby that it is not a cancer.
2. That the gall bladder surgery has certain non life threatening complications and certain grave complications.
3. That the traditional open surgery for gall bladder even today has statistically lesser grave type of complications of
gall bladder surgery compared to the 4 hole surgery called Laparoscopic Cholecystectomy (LC).
4. That LC was introduced into medical science without the acceptable norms of double blind control trials and caused
an enormous increase in the incidence of common bile duct injuries which had grave consequences in many patients
including death.
5. That even after the learning curve the latest available overall data from SAGES* states that the over all common
bile duct injury rate is still very high. 1.4% as compared to 0 to 0.1% in open cholecystectomy.
*SAGES: SOCIETY OF AMERICAN GASTROINTESTINAL & ENDOSCOPIC SURGEONS
http://www.medscape.com/viewarticle/506432
The introduction of laparoscopic cholecystectomy (LC) in the late 1980s ushered in the era of minimally invasive
general surgery. Since then, it has become the preferred approach for cholecystectomy. During the initial years of LC,
when surgeons were in the "learning curve" of the procedure, there was a significant increase in bile duct injuries
(BDIs) compared with open cholecystectomy. However, most surgeons are now past their learning curve, and many
consider LC to be a "basic" laparoscopic procedure. Nevertheless, with the current incidence of BDIs as high as 1.4%,
[1,2] these injuries continue to be very morbid complications that have significant legal and financial implications.
6. More than 770,000 cholecystectomies (gall bladder removal surgery) are done annually in USA and approximately
an equal number in Europe, making it a very common surgical procedure.
Thus some 10780 are suffering common bile duct injuries annually in USA and an equal number in Europe.
7. That beyond these injuries an equal number of other grave injuries occur during Laparoscopic surgery for gall
bladder removal. That even such injuries are caused which are never even possible in open surgery for gall bladder
removal.
8. That to avoid injury to bile ducts a part of gall bladder called cystic duct was advocated to be left inside the patient.
This part is always removed in open surgery to prevent reformation of another sac called pseudo gall bladder which
can cause stones, colic and other problems.
9 That these complications are an inherent part of the surgical procedure and it is mostly NOT the surgeon’s fault
since the surgeon uses best of his judgment to deliver safe surgery to the patient. It is well documented in the
literature that bile duct injury is inherent to Laparoscopic surgery for gall bladder removal and not a lack of skill,
experience of judgment on part of the surgeon.
SURGICAL ENDOSCOPY Vol 20 Number 11 NOV 2006 has devoted its editorial & first 5 articles to the BILE DUCT INJURIES
caused during LAPAROSCOPIC CHOLECYSTECTOMY
2. That the gall bladder surgery has certain non life threatening complications and certain grave complications.
3. That the traditional open surgery for gall bladder even today has statistically lesser grave type of complications of
gall bladder surgery compared to the 4 hole surgery called Laparoscopic Cholecystectomy (LC).
4. That LC was introduced into medical science without the acceptable norms of double blind control trials and caused
an enormous increase in the incidence of common bile duct injuries which had grave consequences in many patients
including death.
5. That even after the learning curve the latest available overall data from SAGES* states that the over all common
bile duct injury rate is still very high. 1.4% as compared to 0 to 0.1% in open cholecystectomy.
*SAGES: SOCIETY OF AMERICAN GASTROINTESTINAL & ENDOSCOPIC SURGEONS
http://www.medscape.com/viewarticle/506432
The introduction of laparoscopic cholecystectomy (LC) in the late 1980s ushered in the era of minimally invasive
general surgery. Since then, it has become the preferred approach for cholecystectomy. During the initial years of LC,
when surgeons were in the "learning curve" of the procedure, there was a significant increase in bile duct injuries
(BDIs) compared with open cholecystectomy. However, most surgeons are now past their learning curve, and many
consider LC to be a "basic" laparoscopic procedure. Nevertheless, with the current incidence of BDIs as high as 1.4%,
[1,2] these injuries continue to be very morbid complications that have significant legal and financial implications.
6. More than 770,000 cholecystectomies (gall bladder removal surgery) are done annually in USA and approximately
an equal number in Europe, making it a very common surgical procedure.
Thus some 10780 are suffering common bile duct injuries annually in USA and an equal number in Europe.
7. That beyond these injuries an equal number of other grave injuries occur during Laparoscopic surgery for gall
bladder removal. That even such injuries are caused which are never even possible in open surgery for gall bladder
removal.
8. That to avoid injury to bile ducts a part of gall bladder called cystic duct was advocated to be left inside the patient.
This part is always removed in open surgery to prevent reformation of another sac called pseudo gall bladder which
can cause stones, colic and other problems.
9 That these complications are an inherent part of the surgical procedure and it is mostly NOT the surgeon’s fault
since the surgeon uses best of his judgment to deliver safe surgery to the patient. It is well documented in the
literature that bile duct injury is inherent to Laparoscopic surgery for gall bladder removal and not a lack of skill,
experience of judgment on part of the surgeon.
SURGICAL ENDOSCOPY Vol 20 Number 11 NOV 2006 has devoted its editorial & first 5 articles to the BILE DUCT INJURIES
caused during LAPAROSCOPIC CHOLECYSTECTOMY
| Do we know that: |