IATROGENIC INJURIES OF SUBVESICAL BILE DUCT - CASE REPORT AND LITERATURE REVIEW

Abstract

With the rise of laparoscopic cholecystectomy as the gold standard for treating gallbladder calculi and
polyps, subvesical bile ducts are gaining increased clinical importance. With the introduction of electrocautery in
surgery, a large part of these tubular structures, although with interrupted continuity, do not show extravasation of
bile content postoperatively. Decreased bile production during general anesthesia and increased intraperitoneal
pressure also make diagnosis of injuries difficult. Surgeons who frequently operate in the right upper quadrant have
to understand the anatomy of the biliary tree and its tendency for structural variation. The work of laparoscopic
surgeons should be conceptualized around three main goals: to enable safe identification of key anatomical
structures, usually by providing a critical point of safety (Critical View of Safety), to make a decision at the right
moment not to proceed with laparoscopic surgery when working conditions become too dangerous and there is no
possibility of identification of structures and to end the laparoscopic surgery with subtotal cholecystectomy when
identification of structures is impossible. Controversy among authors on the naming of the various subvesical
structures causes confusion in their identification and description. In order to overcome these challenges, there was a
need to establish classification systems for post-cholecystectomy lesions of the biliary tract. But due to the
individual shortcomings of all these systems, in June 2011, during the 19th meeting of the European Association for
Endoscopic Surgery in Turin, Italy, a conference was held to reach a consensus to establish a uniform classification
of iatrogenic bile duct injuries that will have two primary goals: first, to take into account changes in the type of
injuries with the introduction of laparoscopic cholecystectomy, and second, to combine all existing classification
systems and integrate them into one, universally accepted classification system. As part of the new inclusive
classification system for iatrogenic injuries of the biliary ducts, the following systems are considered: Bismuth,
Strasberg et al., McMahon et al., AMA, Neuhaus et al., Csendes et al., Steward et al., Hanover, Lau and Lai ,
Siewert et al., Cannon et al., Kapoor., Sandha et al.. In the new system a total of fifteen classifications are
incorporated using semantic connotations and grouped into three categories that will allow easy memorization by
surgeons. A (anatomy) for anatomy, To (time of) for time/moment of observation and M (mechanism) for the
mechanism of occurrence of the injury. By enabling a more precise classification of each of the injuries, the surgical
community will have the opportunity to develop recommendations for prevention, treatment and prognosis for their
outcome.