Gall bladder removal (“cholecystectomy”) is one of the more common surgeries in the U.S. One estimate places the number of these procedures in excess of 750,000 annually in the United States. Until the late 1980’s/early 1990’s, surgeons removed the gall bladder through a three to four inch incision in the patient’s abdomen. The procedure (“open” cholecystectomy) required a three to four day hospital stay after surgery and a recovery period of several weeks. In the late 1980’s/early 1990’s, surgeons in the U.S. began removing gall bladders “laparoscopically.” The laparoscopic method does not require a large incision; usually is an outpatient procedure, which allows the patient to return home the day of surgery; and has a two or three day recovery period. Now, the vast majority (approximately 90%) of cholecystectomies are laparoscopic.
The gall bladder is at the bottom of the liver and is just beneath the rib cage on the right. The cystic duct exits the gall bladder and connects the gall bladder to the common bile duct, forming a “T” junction. The common bile duct, in turn, connects the liver to the intestines. At the entry point to the liver, the common bile duct divides in two, forming the left hepatic duct and the right hepatic duct.
In removing the gall bladder, the surgeon clips the cystic duct in two places. One is near the cystic duct ‘s juncture with the gallbladder, and the second is at the cystic duct’s juncture with the common bile duct. The surgeon similarly clips the cystic artery. The surgeon then transects (cuts) the cystic duct and artery between the two clips. By transecting the cystic duct and artery, the surgeon frees the gall bladder for removal.
The surgeon must find and identify the cystic duct’s juncture with the gall bladder and the cystic duct’s juncture with the common bile duct before transecting the cystic duct. The surgeon accomplishes this by finding the gall bladder and the cystic duct juncture; and then meticulously tracing the cystic duct to its junction with the common bile duct. The objective is to identify the cystic duct conclusively. The surgeon must not clip the cystic duct or transect it before making conclusive identification of the cystic duct.
Unfortunately, laparoscopic cholecystectomies (LC’s) do not always go as planned. The most common mistake is that the surgeon clips or cuts the patient’s common bile duct instead of the cystic duct (an injury caused by a physician is an “iatrogenic injury.”). The medical literature places the frequency of this mistake at 0.1% to 0.5%, and describes the consequences as “severe” and a “dreaded complication.” Even though the overall mortality of LC is 0.45%, it can be as high as 9% after a bile duct injury. The injury usually requires extensive, complicated, painful and expensive ($250,000 plus or minus) surgery (Roux N Y) to reconstruct the patient’s biliary anatomy. Once the patient’s biliary anatomy has been reconstructed, there will be a long period of convalescence; and the reconstructive surgery does not always result in the patient’s being ”out of the woods.” After reconstructive surgery, the patient is at risk for scarring and stricturing of the reconstructed biliary tract and further reconstructive surgery. In the worst case scenario, the patient can develop liver failure and die.
There is much written about iatrogenic biliary tract injury during gall bladder surgery. There also is a considerable amount of litigation as the result of these mistakes. The basic rule is that the surgeon must conclusively identify the cystic duct before clipping or transecting; if, in fact, the surgeon makes the conclusive identification, the injury will not occur. The resulting litigation focuses on that one rule: the surgeon failed to conclusively identify the cystic duct. As the result, the surgeon placed clips across common bile duct, obstructing the flow of bile; or transected the patient’s common bile duct, resulting in the flow of bile into the patient’s abdomen and consequent sepsis.