Common bile duct injury during laparoscopic cholecystectomy and the use of intraoperative cholangiography: adverse outcome or preventable error?

BACKGROUND: Common bile duct (CBD) injury is a serious complication of laparoscopic cholecystectomy (LC). Predictors of this adverse outcome have not been well documented.

HYPOTHESIS: Surgeon experience and the use of intraoperative cholangiography (IOC) are associated with a decreased rate of major CBD injury during LC.

DESIGN: A retrospective population-based cohort study.

SETTING: Washington State hospital discharge database reports from 1991 through 1998.

PATIENTS: Discharge reports were searched for International Classification of Diseases, Ninth Revision, procedure codes consistent with LC and then evaluated for procedure codes for CBD repair and reconstruction within 90 days of LC.

MAIN OUTCOME MEASURE: The rate of CBD injury in patients undergoing LC based on the surgeon's experience and IOC use.

RESULTS: In all, 30 630 LCs and 76 major CBD injuries (2.5/1000 operations) were identified in this analysis. There were no significant differences between injured and noninjured patients in demographics, disease, payer status, or hospital variables. A CBD injury occurred in 3.2 of 1000 LCs in the early case order of surgeons compared with 1.7 per 1000 at later points (P = .01) (relative risk, 1.81; 95% confidence interval, 1.44-2.88). The rate of injury in LCs performed without IOC was 3.3 per 1000 compared with 2.0 per 1000 in LCs with IOC (P = .02) (relative risk, 1.7; 95% confidence interval, 1.1-2.6). Surgeon's experience and IOC use were independent predictors of injury.

CONCLUSIONS: The rate of CBD injury is significantly lower when IOC is used. This effect is magnified during the early experience of surgeons. Systematic use of IOC may significantly reduce the rate of CBD injury.