Frequency of Bile Duct Injury during Laparascopic Cholecystectomy Procedures

Objective: To determine the frequency of bile duct injury during laparascopic cholecystectomy procedures. Study Design: This is an observational study. Setting: Study carried out at General Surgery department, Shaheed Benazir Bhutto Medical College, Lyari Karachi, from July 2019 to August 2021. Materials and Methods: All diagnosed patients of gallstones on the clinically and findings of ultrasound of abdomen with age (20-60 years), gender were included in study. Patient not willing for surgery, pregnant ladies, bleeding disorders, obstructive jaundice and carcinoma of gall bladder were excluded from this study. Results: Out of 162 patients, there were 15 males (9.25%) and 147 females (90.74%), with a male to female ratio of 1:11.6. The mean age was 36.01±8.11years (20 to 60 years). According to our observation, there were 6 cases (3.70%) of common bile duct injury during the operation. Treatments offered range from ERCP and conservative treatment to reconstructive surgery. Four patients (2.46%) were converted to open cholecystectomy, 1 patient underwent open Original Research Article Mangi et al.; JPRI, 34(1B): 58-62, 2022; Article no.JPRI.82753 59 cholecystectomy subsequent ERCP, and 1 patient underwent open Cholecystectomy with Subsequent Reconstructive surgery. Conclusion: In our study bile duct injury commonly occur during laparoscopic cholecystectomy. Over time, improving surgical technique and experience reduced the overall incidence of CBD injuries.

cholecystectomy subsequent ERCP, and 1 patient underwent open Cholecystectomy with Subsequent Reconstructive surgery. Conclusion: In our study bile duct injury commonly occur during laparoscopic cholecystectomy. Over time, improving surgical technique and experience reduced the overall incidence of CBD injuries.

INTRODUCTION
The worldwide common pathology of the gallbladder is cholelithiasis. Gall stones occur in about 10-15% of adults worldwide and are more common in women [1]. Laparoscopic cholecystectomy has changed the treatment strategy for patients with cholelithiasis. Because of the minimal pain and disability associated with the procedure, the procedure was quickly accepted as the treatment of choice for most patients with symptomatic stones [2]. Serious complications were observed when common bile duct injury occur during laparoscopic cholecystectomy. Common bile duct injuries are associated with postoperative morbidity and mortality and reduced life expectancy, especially when they go unrecognized [3].
Inexperience and familiarity with endoscopic anatomical interpretation can lead to iatrogenic biliary injury. This has fallen to less than 0.5% because of the growing experience of surgeons and the availability of better quality equipment [1]. Other causes of bile duct injury include adhesions near the surgical field, use of diathermy near the bile duct, excessive dissection near the Calot's triangle and unexpected bleeding [7,8,9]. This study focuses on frequency of iatrogenic biliary injuries.

MATERIALS AND METHODS
This observational study was conducted at the Surgical departments of Shaheed Benazir Bhutto Medical College, Lyari Karachi Pakistan, from July 2019 to August 2021. All diagnosed patients of gallstones on the clinically and findings of ultrasound of abdomen with age (20-60 years), gender were included in study. The patient did not give consent for surgery, pregnant ladies, bleeding disorders, obstructive jaundice and carcinoma of gall bladder were excluded from this study. The cases were operated by surgeons with different levels of experience. Standard four port technique was used. Data were analyses by using Statistical Package for Social Science (SPSS) software, Version 22.

RESULTS
Laparoscopic cholecystectomy were performed in 162 patients. Among the 162 patients, there were 15 males (9.25%) and 147 females (90.74%), with a male to female ratio of 1:11.6. The mean age was 36.01±8.11years (20 to 60 years). According to our observation, there were 6 cases (3.70%) of common bile duct injury during the operation (

DISCUSSION
Iatrogenic biliary injury is a serious complication of biliary surgery and presents a major challenge not only to primary surgeons but also to experienced referral centers [10,11]. It has long been associated with prolonged morbidity and increased early mortality [12]. The incidence of cholelithiasis depends upon the age groups. 63 cases (38.88%) with the highest incidence recorded in the third decade of life followed by 49 cases (30.24%) during 4th decade of life followed by 49 cases (30.24%) during 4 th decade of life. While the compared with the study of A. Viste was reported mostly 67 patients observed between range 14-86 median age of 55 years.

Chart 1. CBD injuries management
An other international study conducted by Supriya Sharma et al. [13] showing higher incidence observed in 3rd and 4th decade group were most commonly involved. In general, cholelithasis are less common in males. The ratio of male: female in the present study comes approximately to 1:11.6. In present study the percentage of males is 9.25% and that of females is 90.74%. Our findings closely correlate with Cosmin Moldovan [14] who observed ratio of 2.7:1 in favor of female patients with an average age of 47 years, with limits between 20 and 85 years.
The common bile duct injuryis the most serious complication of the Laparoscopic Cholecystectomy procedure. An international surveyconducted in Italy on 56,591 Laparoscopic Cholecystectomies done in 187different centers was observed 0.42% common bile duct injury [15]. In the initially days of laparoscopic cholecystectomy.
Increased incidence of injury is associated with the surgeon's learning curve, the significantly increased the incidence so the reduced the volume of laparoscopic cholecystectomy performed. The international study by Boddy on laparoscopic cholecystectomies over ten years observed the low incidence of CBD injury for hepatopancreatic biliary surgeons as compared to the consultant general surgeon ( 0.1% Vs 0.9%) [16]. Over time, they experience a significantly decreased incidence of CBD injury with an increasing number of LCs performed. One team has done 150 laparoscopic cholecystectomies in three years, around 0.9% incidence of CBD injury observed, while another team who done over 450 laparoscopic cholecystectomies had an incidence of CBD injury of approximately 0.3% [16]. In 2006, Hobbs reviewed 22,789 cases observed, with passaging time CBD injuries decreased day by day 1994 to 1998 (from 0.35% to 0.13%) [17]. In 2011, an analyzing the series 234280 LCs by Harrison reported no marked difference in the incidence of bile duct injuries (0.24% vs. 0.26%) between the experienced surgeons and residents [18]. While in our study observed CBD injury during LC was 3.70%. However, in our study, there is a significant impact experience in LCs on the incidence of iatrogenic bile duct injury.

CONCLUSION
In all cases of cholecystectomy, common bile duct damage remains a serious complication. Over time, improving surgical technique and experience reduced the overall incidence of CBD injuries.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.