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Video nasty

01 February 2006

Mrs P, a 37-year old housewife, presented with recurrent attacks of biliary colic. Gallstones were confirmed on abdominal ultrasound and Mrs P consulted Dr H, a general surgeon. Dr H arranged a laparoscopic cholecystectomy, warning the patient of the risks of open conversion, but did not mention more serious complications.

At the time of surgery, Dr H noted a distended, thick-walled gall bladder with no other abnormality identified. He used a standard, four-port approach, documenting that the cystic duct was freed, clipped and divided with adequate haemostasis before removing the gallbladder. The procedure was recorded on video.

Mrs P developed abdominal pain and vomiting postoperatively, which slowly resolved. Dr H examined the patient on three occasions and did not find anything of concern; the liver function tests were not checked. Mrs P was well enough to be discharged home 48 hours after surgery, but returned six days later.

Although Dr H did not note this consultation, Dr H recalled no abnormality on examination. Nevertheless, he arranged further frequent follow-up and investigation looking for the development of jaundice.

Mrs P developed progressive severe obstructive jaundice over the next two months and was seen by Dr C, who arranged an endoscopic retrograde cholangiopancreatography (ERCP). This demonstrated a completely obstructed bile duct at a level corresponding with several metal clips.

A percutaneous transhepatic cholangioscopy (PTC) was performed confirming a grossly dilated, tortuous biliary tree. Dr A, a hepato-pancreato-biliary surgeon, operated on Mrs P the same day noting a congested liver with the proximal common hepatic duct completely obstructed by six metal ligaclips. A hepatico-jejunostomy was performed with an uneventful postoperative recovery.

Mrs P sued Dr H, who was indemnified by MPS. Our experts and those of the plaintiff reviewed the operative video. Both commented that the anatomy of the cystic duct and common hepatic duct junction was inadequately demonstrated.

Traction on the cystic duct led to the inappropriate ligation of the main duct, which eventually caused complete occlusion. Our expert also questioned Dr H’s repeated references to possible postoperative jaundice and his unusual follow-up plan for Mrs P.

MPS settled the claim for a sum equivalent to £31,000 (US$54,000) inclusive of costs.

Learning points

  • Always warn patients of potentially serious postoperative complications and document this discussion. The incidence of major bile duct injury is only 0.3% but this is a potentially devastating complication often requiring further corrective surgery with potential long-term morbidity.
  • Great care and attention is required to dissect out the anatomy of Calot’s triangle to ensure that the cystic duct is correctly ligated and divided. In difficult cases an operative cholangiogram can clarify the situation. Such an approach may diagnose a bile duct injury at an earlier stage or avert more serious damage.

Further reading

See Krahenbuhl et al, Incidence, Risk Factors and Prevention of Biliary Tract Injuries During Laparoscopic Cholecystectomy in Switzerland; World J Surgery 25(10):1325–30 (2001).