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Masjid Nabawi –dream destination for          any Believer‫ن ّ وملئكت يصل ن عل نبي ي َيه لذ ن‬َ ‫إِ ّ ا َ َ َ َ ِ َ َه ُ ُ...
My VisionThe right care for every person every time.
Strategies for Lowering the Rate of Bile Duct                                               Injuries in Laparoscopic Chole...
Congressman: Murtha Died    After Intestine Was    Damaged in Gall bladder    Surgery Rep. John Murtha (D-PA), the  first...
Present status of Post lap chole-biliary duct injuries-       A Quality Manager’s overview…    How can we improve? Debatab...
 َ َ ِ ْ َ ‫َ َا ِن َآّ ٍۢ ِى ٱ‬  ‫لْرض ول‬      ‫و م م د بة ف‬  ‫طَ ئر يط ر بجن ح ه إل أمم‬  ٌ َ ُ ّٓ ِ ِ ْ‫َٓ ِ ٍۢ َ ِ...
ollaboration among Surgeons, Gastroenterologists andinterventional Radiologists is imperative in the management of        ...
   A good story during the incidents, the    explosion of a plant in Nanjing, China on July    28, 2010 . Event of a cras...
Case 1        A 55 years old male Yemeni. Had post-  cholecystectomy CBD injury.;Detected post  operative period ;Surgeon ...
US for the liver
First ERCP in 09/12/06
DR .Fazal I ;Khawaja ,              DR Abd Salam-Consultant & HeadConsulatant Gastrio -Enterologist   interventional Radio...
US Guided PTC in 13/12/06
PTC, showed a sealed biloma, at the GB bed ,                with no leak.
Trials for PTD down to the Duodenum for two                     Hours
Suddenly, the guidewire slipped through down             to the Duodenum !!!?
Live video
ERCP and Radiology Imaging and Interventionalmanagement of Peri op complication of Lap choleare an effective Diagnostic an...
“we [general surgeons]had already losttraditional surgical fieldslike polypectomy,papillotomy, and noweven endoscopicappen...
Picture of the abdomen of the first patient to havelaparoscopic cholecystectomy, September 12, 1985, showingportholes in t...
 Basic pistol grip hemoclip applier and scissors made for W.  Reynolds, Jr, MD, in 1972.
 Mühes open tube laparoscopic cholecystectomy, Technique No. 2. Patient with 1 access, directly above the gall- bladder w...
The spectrum of mishap has alsochanged due to the involvement ofnew instruments/technique such as;stapling device,hook sci...
Surgeons rushed in massive numbers to learn the surgery, taking weekend courses—toadd laparoscopic surgeon to their busine...
 1992 NIH safety approval Lap chole ----- An increase  from 0.1% to about 0.6% -5%(x10 times)  WERE been noted ; As of 2...
It was a plausible and logical argument that theabrupt rise in bile duct injuries associated with the       earliest effor...
Laparoscopic Bile Duct Injuries    • Bile Duct Injuries - Incidence • Laparoscopic Cholecystectomy-   Deziel     (1993)   ...
Certainly, it has not been for a lack of research on laparoscopiccholecystectomy. A Medline review found more than 20000 a...
 a) Doing the right thing right the first time only. b) Doing the right thing right the next time. c)   Doing the right...
Negligence orAn inherentprocedural risk-
Objective To apply human performance concepts in an attempt to understandthe causes of and prevent laparoscopic bile duct ...
These LESSON OFTENWE FORGET…
To improve our results, we need toaccurately identify the cause of ourmistakes-             Suggest RECOMMENDATIONS-..To a...
Level I   Evidence from properly conducted randomized, controlled trialsLevel     Evidence from controlled trials without ...
 Policy and procedures--  Who should do what ? Do we need to certify or  accredit,any hospital or  pvt nursing homes bef...
Safe surgeon     To this day, there are a lot of doctors performing this surgery     who should not be performing the surg...
"A good surgeon knows how to                                                      Reasonable knowledgeoperate             ...
There is increased rate of cholecystectomies after laparoscopic era?Are we operating on right kind of patients or we have ...
Indications                           Contraindications- “Most patients with symptomatic      Relative contra-indication...
 AsymptomaticDid you know?Majority of people with                                            gallstones: Should wegallsto...
11:6There is no moving creature onearth but its sustenance dependethon Allah: He knoweth the time andplace of its definite...
Is the Main problem misperception of ductal anatomy—or Surgeonrelated(“)Attitude of Surgeon”?
 Risk Factors ◦ Anatomical   ◦ Anatomical variations (biliary and vasculature)   ◦ Bleeding, scarring, obesity ◦ Laparosc...
Video assisted Lap -Operation is on image-lackof tactile sensation,contrast and depth ofvision –(integrity of eye ;brain; ...
 In the open approach,      Standard exposure  the gallbladder and        provided by laparoscopy  the biliary tree are ...
Biliary anatomy variationsshould be imprinted in theminds of all surgeonsduring lap chole                             Anat...
Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cmwith common hepatic duct (15-25%); F,G,H. M...
 Refers to common hepatic duct obstruction caused by  an extrinsic compression from an impacted stone in  the cystic duct...
 The safety of  laparoscopic  cholecystectomy  requires correct  identification of  relevant anatomy.  (Level I, Grade A)...
 In the 1990s , high rate( 2% -5%) of biliary injury was  due in part to learning curve effect. A surgeon had a 1.7% cha...
. Excessive traction leading to tenting of the CBD is  another factor predisposing to clipping and ligation of  the bile...
Misperception IS THE MAIN PROBLEM
 The common bile duct                                         is mistaken for the                                        ...
 --Mistaking the common  bile duct for the cystic duct Pulling forcefully/ duct-Cephalad traction up on the GB when clipp...
 Inappropriate use of electrocautery near or around the CBD may damage its axial blood flow, leading to ischemic damage t...
 Local risk factors ; 15–35% of BDI   Bleeding in Calot’s triangle, Severely Scarred or shrunken gall    bladder,. ;Infl...
Can we minimize it ?—what are modifiable factors-?Pt related –no ;Equipment-Environment –(some minimum requirements)Surgeo...
Rules of thumb to help prevent bdi
 Adequate and proper training in a laparoscopic surgery,    delineation of biliary anatomy in Calots triangle (critical v...
 Attention to operative details (insufficient close or  deep plane) Stasberg’s critical view of safety Appropriate Hand...
Dissection within                          the triangle of                          Calot to                          demo...
 Surgeons with more experience have the lowest    complication rates   Furthermore, credentialing for laparoscopic surge...
BASIC   Advanced
 IOC - may reduce the rate or severity of injury    and improve injury recognition. when used    routinely and allows acc...
 Intraoperative  cholangiogram shows  filling of distal bile duct  with flow into the  duodenum. The lack of  retrograde ...
 Dome down technique-- Dissection of the  gallbladder from the liver bed:The more  conventional approach starting at the ...
 Conversion should not be  considered a complication and  surgeons should have a low  threshold for conversion; Decision...
Use of the checklist reduced the rate of deaths andcomplications by more than 1/3 across all 8 pilothospitals. (Canada;Ind...
CHECK YOUR TYRES   BEFORE ANY JOURNE Y--
 Type A ;Cystic duct leaks  or leaks from small ducts  in the liver bed Type B ;Occlusion of a  part of the biliary tree...
   E: injury to main    duct (Bismuth)     E1 : Transection        >2cm from        confluence       E2 : Transection  ...
Co-mmunicate with patient and /or relatives
Bile Duct Injuries• How do you get Suspicion DURING OR—(intra operatively)          •   Atypical anatomy         •    “Acc...
 Only 25-33% of injures are recognized intraoperatively  1. Expertise available ; Convert to Open Procedure and     perfo...
 The classic injury is when the CBD is mistaken for the    cystic duct. Once the gallbladder has been removed, it is    i...
   Patient presents with…clinically     Vague abdominal pain, nausea, fever, jaundice, vomiting Investigation Blood –l...
 HIDA – presence of active bile leak (physiologic
US/CT – detect bilomas + Per cut Drainage)
 Provides exact anatomical diagnosis of bile duct leak;  while allowing treatment w/ decompression of the  biliary tree....
POST-OPERATIVE BILE LEAKS &        BILIARY FISTULASLimitations of ERCP—PTC –MRCP superior but non therupeticInability to v...
POST-Lap choleBILE LEAKS & BILIARYFISTULAS : ROLE OF ERCP=goodgastroenterologist is a help                                ...
Our experience (15yrs)Lap – Chole Related Bile leaks:    Cystic duct stump              27(40%)     Duct of Lushka        ...
ERCP   helps in diagnosis and removes any doubts regarding possible major ductal injuries.The condition resolves spontaneo...
Site of bile leaks:Duct of Lushka (DOL)
Bile leaks with luminalnarrowing of MBD
Careful flouroscopic observation of leakage point of originAn un-experienced & poorly equiped Endoscopist is thesurgeons w...
Figure 2: MRCP revealing subhepatic and                                                    significant intra-abdominal bil...
POST-OPERATIVE BILE LEAKS &       BILIARY FISTULASLimitations of PTC and ERCPInability to visualise the biliary tree beyon...
 examine the source of bile leak Although bile may leak from an opening in the GB or the cystic  duct, before that is pr...
 Type-magnitude Expertise availbility Bile leak-Partial-Complete Bile-Obstruction ;clipping; Management differs
 The goal of surgical repair of the injured biliary tract is  the restoration of a durable bile conduit, and the  prevent...
 Controlling sepsis, establish biliary drainage, postulate  diagnosis, type and extent of the bile duct injury. Broad-sp...
Site of bile leaks:Cystic duct +Stent
Surgical management
            Injury to a major duct (right hepatic  duct/CHD or CBD) has more serious consequences. In  the event of this ...
 A lateral/incomplete injury (involving partial  circumference of the duct) may be repaired with fine  (4-0/5-0) suture o...
 If the duct has been divided, it is important to assess if there is associated loss of  a segment of the duct as happen...
 When the bile duct has been divided without excision of  a segment, a primary end to end anastomosis of the cut  ends of...
 in such situations no attempt must be made to repair the injury. Repairs  done by inexperienced surgeons are likely to f...
 In the majority of cases (more than 60%), the biliary injury is unrecognized    at laparoscopic cholecystectomy   A hig...
 If there is no bile leak, the patients may not have any  symptoms and signs in the early postoperative period and  may d...
 More often a biliary stricture develops (with dilated proximal ducts) which will require a hepaticojejunostomy. Placemen...
 Hepaticojejunostomy is preferred to choledochoduodenostomy as  the latter is prone for complications due to reflux chola...
Side to side –anastomosis –bismuth II or III
Outcome results Why? Results by an expert- and results by an routine
 The best outcomes   Early repair (72 hours after LC-BDI)   late repair (>6 weeks after LC-BDI). A minor comment is th...
 EXPERT VS NORMAL ; Successf rate when Surgery performed by/at    Primary surgeon =35%    Specialized Expert( hepatobil...
Suggested flow diagram for patients with suspected bile duct injuryafter laparoscopic cholecystectomy [3].Manouras et al. ...
 Timing of diagnosis;Expertise availability; SEPSIS ETC Endoscopic stenting for strictures   T-tube placement for minor...
Safe Surgery Saves Lives Frequently
An error during gallbladder surgery ) is a common source ofmedical malpractice claims, largely because this is a commonfor...
 Another common defense is the “patient had unusual  anatomy” or “he/she was too fat to be able to see”  defenses.   Thes...
 Professional negligence is defined as absence of reasonable  care and skill or willful negligence of a medical practitio...
 Bile duct injuries are a major complication of both open cholecystectomy    and LC. It can have devastating effects, tur...
What model should exist in healthcare?          It is argued that not one model           of accountability fits all of h...
“Despite numerous publications    on this topic, there is no simpleQUOTE OF THE DAY    set of rules that inexperienced    ...
 "There is no moving creature  on earth but its sustenance  depends on God: He knows  the time and place of its  definite...
Background to Safe Surgery SavesLives
 The author is indebited to those contributors whose  pictures have been shared with readers here for  purely academic pu...
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims  may262012
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BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims may262012

Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention

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BILE DUCT INJURY__:PREVENTION :MANAGEMENT;When bad things happen to good surgeons fiazfazili skims may262012

  1. 1. Masjid Nabawi –dream destination for any Believer‫ن ّ وملئكت يصل ن عل نبي ي َيه لذ ن‬َ ‫إِ ّ ا َ َ َ َ ِ َ َه ُ ُ َّو َ َ َى ال ّ ِ ّ َا أ ّ َا اّ ِي‬ ‫ل‬‫آ َ ُوا َّوا َ َيْ ِ َ َّ ُوا َسِْيم‬ ‫من صل عل ه وسلم ت ل‬ “yeh bargahi habib haq hai-chalo saroon ko jhuka jhuka kar -durood har ik qadam pai bejoo-niyazemandi dikha dikha kr”
  2. 2. My VisionThe right care for every person every time.
  3. 3. Strategies for Lowering the Rate of Bile Duct Injuries in Laparoscopic Cholecystectomy bile duct injuries A Review --Mechanism, Preventive Measures, and Approach to Management:;;Repair When BAD THINGS HAPPEN TO GOOD SURGEONS ? Why? …where?...who? part1•Quality Manager and Supervisor CME Surgery .•Group leader ---JCI joint commission international for Hospital accreditationSurgical chapter•Editor ( Ass ; Rev ; Online ) international and Medical Journal - Minimalaccess ,;•. slidedworld . com ; ind jr of surgery•–Literature review current through:. This topic last updated Feb 2012Literature review current through: Feb 2012. DR;FIAZ FAZILI –This topic last updated: Jun 8, 2010
  4. 4. Congressman: Murtha Died After Intestine Was Damaged in Gall bladder Surgery Rep. John Murtha (D-PA), the first veteran of the Vietnam war to be elected to Congress and one of its most powerful lawmakers, died Monday afternoon at Virginia Hospital Center in Arlington, Va., after complications from gallbladder surgery. The gallbladder surgery was performed days earlier at the National Naval Medical Center in Bethesda, Md
  5. 5. Present status of Post lap chole-biliary duct injuries- A Quality Manager’s overview… How can we improve? Debatable—Controversies & issues (policy) . ARE WE Practicing –Safe surgery rules ?.P Who is doing What ,at What place ;and on Whom?...t Is BDI following lap chole –prof negligence (Medicalmalpractice) or risk inherant to procedure
  6. 6.  َ َ ِ ْ َ ‫َ َا ِن َآّ ٍۢ ِى ٱ‬ ‫لْرض ول‬ ‫و م م د بة ف‬ ‫طَ ئر يط ر بجن ح ه إل أمم‬ ٌ َ ُ ّٓ ِ ِ ْ‫َٓ ِ ٍۢ َ ِي ُ ِ َ َا َي‬ ‫كتَب‬ ِ َ ِ ْ‫َمْ َا ُ ُم ۚ ّا َ ّطْ َا ِى ٱل‬ ‫أ ث لك م فر ن ف‬ ْ‫ِن َىْ ٍۢ ۚ ُ ّ َِىَ َّ ِم‬ ‫م ش ء ثم إل ر به‬ ‫ي شر ن‬ َ ‫ُحْ َ ُو‬ The Noble Quran- Al- Anam (6:38)- There is not a moving (living) creature on earth, nor a bird that flies with its two wings, but are communities like you. We have neglected nothing in the Book, then unto their Lord they (all) shall be gathered.
  7. 7. ollaboration among Surgeons, Gastroenterologists andinterventional Radiologists is imperative in the management of such injuries
  8. 8.  A good story during the incidents, the explosion of a plant in Nanjing, China on July 28, 2010 . Event of a crash that killed 13 people and injured 300 people tells a lot of attention the fact that suck the public. During the explosion occurred, a monkey was recorded during the camera saves the puppy from the explosion site. They hold the dog as he ran out of the factory. If this event can tap our collective conscience, animals can show compassion and kindness to each other. Gensis powerful high explosive that occurs when a pipe from burning chemical factory in China. The explosions occurred in Nanjing, Jiangsu provincial capital, about 10.00 am. In addition to deaths and injuries, the explosion also damaged the surrounding area. windows of houses, shops and offices were damaged and affect the extent to 300 meters. While other people thought was an earthquake.
  9. 9. Case 1 A 55 years old male Yemeni. Had post- cholecystectomy CBD injury.;Detected post operative period ;Surgeon referred to Gastro enterologist/.Dr.Fk,for evaluation / management, from ,,,,,,,,(……. Hospital) Dr. FK referred the patient for US esp- Heaptobiliary area.Then he performed the First ERCP for the Patient, in 9/12/2006
  10. 10. US for the liver
  11. 11. First ERCP in 09/12/06
  12. 12. DR .Fazal I ;Khawaja , DR Abd Salam-Consultant & HeadConsulatant Gastrio -Enterologist interventional Radiology
  13. 13. US Guided PTC in 13/12/06
  14. 14. PTC, showed a sealed biloma, at the GB bed , with no leak.
  15. 15. Trials for PTD down to the Duodenum for two Hours
  16. 16. Suddenly, the guidewire slipped through down to the Duodenum !!!?
  17. 17. Live video
  18. 18. ERCP and Radiology Imaging and Interventionalmanagement of Peri op complication of Lap choleare an effective Diagnostic and Therapeuticmodality. A great relief and help ..lap surgeon The technical skill, experienced hand and goodknowledge of the different procedures are requiredto increase success and limit complication rate.
  19. 19. “we [general surgeons]had already losttraditional surgical fieldslike polypectomy,papillotomy, and noweven endoscopicappendectomy .I was convinced that ifwe passed up thischance like endoscopiccholecystectomy,internists andgynecologists wouldagain take away a pieceof ourcompetence….”Muhe
  20. 20. Picture of the abdomen of the first patient to havelaparoscopic cholecystectomy, September 12, 1985, showingportholes in the lower abdomen.
  21. 21.  Basic pistol grip hemoclip applier and scissors made for W. Reynolds, Jr, MD, in 1972.
  22. 22.  Mühes open tube laparoscopic cholecystectomy, Technique No. 2. Patient with 1 access, directly above the gall- bladder without pneumoperitoneum because the costal arch is a firm bone roof.
  23. 23. The spectrum of mishap has alsochanged due to the involvement ofnew instruments/technique such as;stapling device,hook scissors; & energizedinstruments New Complications like; migrating clips or spillage of gallstone;thermal injurues into peritoneal cavity were completely unknown in open surgery.
  24. 24. Surgeons rushed in massive numbers to learn the surgery, taking weekend courses—toadd laparoscopic surgeon to their business boards. ;prescription pads
  25. 25.  1992 NIH safety approval Lap chole ----- An increase from 0.1% to about 0.6% -5%(x10 times) WERE been noted ; As of 2012, 0.4%..(OC—0.1-0.3% ). Expected drop in % significantly with ---time/experience.but…it didn’t happen Between 34% and 49% of surgeons are susceptible (expected to )cause such an injury during their career.
  26. 26. It was a plausible and logical argument that theabrupt rise in bile duct injuries associated with the earliest efforts to perform laparoscopic cholecystectomy could be expected to drop significantly once surgeons and residentsprogressed beyond their own learning curve for this novel technique.
  27. 27. Laparoscopic Bile Duct Injuries • Bile Duct Injuries - Incidence • Laparoscopic Cholecystectomy- Deziel (1993) - 0.6%- Wherry (1994) - 0.5%- Wherry (1996) - 0.4%- Nuzzo (2005) - 0.4%- Waage (2006) - 0.4%- Fazili (2010) - / 0.32 % (0.40 / 0.32 / 0.47 )
  28. 28. Certainly, it has not been for a lack of research on laparoscopiccholecystectomy. A Medline review found more than 20000 articlespublished on the subject in 2001 alone. Perhaps processes in play,unrecognized by surgeons, have prevented us from making progress in ourefforts against the learning curve.
  29. 29.  a) Doing the right thing right the first time only. b) Doing the right thing right the next time. c) Doing the right thing right the first time, doing it better the next time---in all time. d) All of the above The answer is====C-Doing the right thing right the first time, doing it better the next time---in all time.  .)
  30. 30. Negligence orAn inherentprocedural risk-
  31. 31. Objective To apply human performance concepts in an attempt to understandthe causes of and prevent laparoscopic bile duct injury
  32. 32. These LESSON OFTENWE FORGET…
  33. 33. To improve our results, we need toaccurately identify the cause of ourmistakes- Suggest RECOMMENDATIONS-..To apply human performance concepts in an attempt to understand the causes of and to prevent laparoscopic bile duct injury
  34. 34. Level I Evidence from properly conducted randomized, controlled trialsLevel Evidence from controlled trials without randomization-OrII Cohort or case-control studies Or Multiple time series, dramatic uncontrolled experimentsLevel Descriptive case series, opinions of expert panelsIII Scale Used for Recommendation Grading Based on high-level (level I or II), well-performed studies with uniformGrade A interpretation and conclusions by the expert panel Based on high-level, well-performed studies with varying interpretation andGrade B conclusions by the expert panel Based on lower level evidence (level II or less) with inconsistent findings and/Grade C or varying interpretations or conclusions by the expert panel
  35. 35.  Policy and procedures-- Who should do what ? Do we need to certify or accredit,any hospital or pvt nursing homes before allowing them to…..lap surgery???? In case of bdi—is there any written PROTOCOL, Arrangement Do we need supervising body of experts….for every splty for monitoring.?
  36. 36. Safe surgeon To this day, there are a lot of doctors performing this surgery who should not be performing the surgery because they are not qualifiedShould we allow every one to do lap surgery -Who is socalled a ,”GoodSurgeon?”What are basic requirements to allow lap chole to be doneby any Surgeon for any set up ?
  37. 37. "A good surgeon knows how to Reasonable knowledgeoperate of Anatomy and fair useA better surgeon knows when to of InstrumentsoperateThe best surgeon knows when not tooperate" Qualified Certified for Open surgery Accreditations-laparoscopy recognized center Low threshold for conversion to open Doesn’t hesitate to call for second opinion-transfer to higher center DO NO MORE HARM?-Respect s tissues- --Respect tust Doesn’t hesitate to call for second opinion- transfer to higher centerpatient rights.
  38. 38. There is increased rate of cholecystectomies after laparoscopic era?Are we operating on right kind of patients or we have conflict in our interest ?To operate or not to operate …on asymptomatic gall stone pts.
  39. 39. Indications Contraindications- “Most patients with symptomatic  Relative contra-indications gallstones are candidates for lap for laparoscopic biliary chole, ". Fit fr g/a; no tract surgery comorbidities  Untreated coagulopathy, l biliary dyskinesia,  ack of equipment, acute cholecystitis, (calcukar  lack of surgeon expertise, or acalcular );  hostile abdomen, Complications related To CBD stones including ‫؛‬  advanced cirrhosis/liver Pancreatitis failure, and  Suspected gallbladder cancer. Ebm=(Level II, Grade A).  Eivdence =(Level II, Grade A).
  40. 40.  AsymptomaticDid you know?Majority of people with gallstones: Should wegallstones never experience operate?any symptoms.  TO OPERATE OROthers remain aysmptomatic (withoutsymptoms) for at least 2 yrs s after the NOT TO OPERATE ONstone formation begins.  ????Is there also a financial motivation that ASYMPTOMATICIf symptoms do occur, the chance of GALLSTONES IN attracts surgeons to this minimally invasivedeveloping pain is about 2% per yearfor the firstprocedurethe stone LAPAROSCOPY ERA 10 yrs after (including a lot of gallbladder removalformation, after which the chancepatients www.wals.org.uk/article.htm procedures for for  that did not deservedeveloping symptoms decrease. removal ?  (Review article).Risk of bile duct injury with  DR Fiaz Maqbool Fazili.laparoscopic cholecystectomy is  #Asymptomatic gall stonesaround 0.2% do not require treatment. (excp high risk grp)
  41. 41. 11:6There is no moving creature onearth but its sustenance dependethon Allah: He knoweth the time andplace of its definite abode and itstemporary deposit: All is in a clearRecord. (52:58  "Surely Allah is the Bestower of provision, Lord of Power, the Almighty".,)
  42. 42. Is the Main problem misperception of ductal anatomy—or Surgeonrelated(“)Attitude of Surgeon”?
  43. 43.  Risk Factors ◦ Anatomical ◦ Anatomical variations (biliary and vasculature) ◦ Bleeding, scarring, obesity ◦ Laparoscopic inherent- ◦ Lack of Depth Perception, Tactile Feedback, Full Manual Maneuverability—working on image ◦ Improper surgical approach –Improper Lateral retraction (insufficient or excessive) ◦ 0 degree scope ◦ Approach plane too deep-too close to CBD-duodenum ◦ ATTITUDE__not sticking to rules of game. ◦ Lack of conversion to OC during difficult cases; ◦ Between 34% and 49% of surgeons are expected to cause such an injury during their career.
  44. 44. Video assisted Lap -Operation is on image-lackof tactile sensation,contrast and depth ofvision –(integrity of eye ;brain; tactile )No camera X megapixels and chips canreplace human eye--“so which of yourLords bounties will youtwo deny?Holy quran Ch AL – RAHMAN )
  45. 45.  In the open approach,  Standard exposure the gallbladder and provided by laparoscopy the biliary tree are distorts the normal viewed from the top alignment of the down, whereas in structures by laterally laparoscopy the biliary retracting the gallbladder structures are viewed and creating an angle in head on- the common hepatic duct (CHD)/common bile duct (CBD).
  46. 46. Biliary anatomy variationsshould be imprinted in theminds of all surgeonsduring lap chole Anatomical abnormalities
  47. 47. Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cmwith common hepatic duct (15-25%); F,G,H. Medial cystic duct insertion(10-17%). Uncommon variants: C. High fusion with hepatic duct; D. Fusion atright hepatic duct; F. No cystic duct.
  48. 48.  Refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct Estimated to occur in 0.7-1.4% of all cholecystectomies Often not recognized preoperatively, which can lead to significant morbidity and biliary injury, particularly with laparoscopic surgery
  49. 49.  The safety of laparoscopic cholecystectomy requires correct identification of relevant anatomy. (Level I, Grade A). Intraoperative cholangiogram may reduce the rate or severity of injury and improve injury recognition. (Level II, Critical view of safety Grade B).
  50. 50.  In the 1990s , high rate( 2% -5%) of biliary injury was due in part to learning curve effect. A surgeon had a 1.7% chance of a bile duct injury occurring in the first case and a 0.17% chance of a bile duct injury at the 50th case.Conflicting with above reports- @However most surgeons passed through learning curve, “steady-state” reached , but there has been no significant improvement in the incidence of biliary duct injuries. Moore M.J.; Bennett C.L , The American journal of surgery 1995 @Mubasher H Khan et al Gastrointest Endosc 2007
  51. 51. . Excessive traction leading to tenting of the CBD is another factor predisposing to clipping and ligation of the bile duct, especially when performing an open cholecystectomy.. Obesity and excessive fat in the porta hepatic area also poses technical difficulties and can predispose to bile duct injuries. [9]
  52. 52. Misperception IS THE MAIN PROBLEM
  53. 53.  The common bile duct is mistaken for the cystic duct and transected. A variable extent of the extrahepatic biliary tree is resected with the gallbladder.Cephalad traction on GB to tent theCBD out of normal location, leadingto clip placement at the cystic duct-CBD junction
  54. 54.  --Mistaking the common bile duct for the cystic duct Pulling forcefully/ duct-Cephalad traction up on the GB when clipping the cystic duct  tenting injury to the junction of the CBD & common hepatic. Duct.to
  55. 55.  Inappropriate use of electrocautery near or around the CBD may damage its axial blood flow, leading to ischemic damage to the duct and late stricture formationThermal necrosisductal tissue loss May lead to bile leaks or delayed stricture Mechanical trauma can have similar effects
  56. 56.  Local risk factors ; 15–35% of BDI  Bleeding in Calot’s triangle, Severely Scarred or shrunken gall bladder,. ;Inflammation -; Mirizzi’s syndrome ;Large impacted gallstone in Hartmann’s pouch, Short cystic duct, Acute cholecystitis, Acute biliary pancreatitis Abnormal biliary anatomy]. Lack of Experience or overconfidence+++  More than ½ (half) of all such injuries occurred during the so called “easy” LC performed by an inexperienced surgeon . ] Male sex and prolonged surgery~ for more than 120  minutes -independent risk factors
  57. 57. Can we minimize it ?—what are modifiable factors-?Pt related –no ;Equipment-Environment –(some minimum requirements)Surgeon related—attitude-technique –-credentialing-revalidation RULES OF THUMB TO HELP PREVENT BILE DUCT INJURIES
  58. 58. Rules of thumb to help prevent bdi
  59. 59.  Adequate and proper training in a laparoscopic surgery, delineation of biliary anatomy in Calots triangle (critical view) by careful surgical dissection, . if need be by intra-operative cholangiography (IOC), in difficult cases , Avoiding blind application of clips, cautery in case of bleeding in the Calot’s triangle are some of the measures to avoid a BDI judicious use of electrocautery, The primary cause of error was visual perceptual illusion in 97% of the cases . Fault in technical skill was present in only 3% of injuries. [Br J surg and Am j surg 2005.2008).
  60. 60.  Attention to operative details (insufficient close or deep plane) Stasberg’s critical view of safety Appropriate Handling of Gallbladder Careful use of diathermy Recognition of Biliary and Vasculature Anomalies
  61. 61. Dissection within the triangle of Calot to demonstrate the cystic duct and artery clearly entering the GBCritical view of safety
  62. 62.  Surgeons with more experience have the lowest complication rates Furthermore, credentialing for laparoscopic surgery is now becoming a reality. Many institutions currently, or soon, will require proof of a fundamental skill-set in basic laparoscopy for credentialing purposes. (SAGES) have developed a validated assessment tool named Fundamentals in Laparoscopic Surgery (FLS)]. FLS is now required by the American Board of Surgery to qualify for the surgical certification examination.
  63. 63. BASIC Advanced
  64. 64.  IOC - may reduce the rate or severity of injury and improve injury recognition. when used routinely and allows access to the biliary tree for therapeutic intervention; (Level II, Grade B).• Routine IOC is technically challenging, adds cost and time to the procedure & is unnecessary for the majority of patients— • Laparoscopic cholecystectomy without cholangiography: Is it a safe procedure? • O M Elhassan and F M Fazili Minim Invasive Ther 4(4):219 - 222 (1995)•• Few Surgeons selectively use preoperative (ERCP) and perform IOC based on abnormal LFT or a dilated CBD or /on preoperative USG.
  65. 65.  Intraoperative cholangiogram shows filling of distal bile duct with flow into the duodenum. The lack of retrograde flow into the proximal biliary tree is concerning. A clip may be present occluding the bile duct proximally.
  66. 66.  Dome down technique-- Dissection of the gallbladder from the liver bed:The more conventional approach starting at the gallbladder infundibulum and working superiorly, or the top down approach, may be used with electrocautery, ultrasonic dissection, or hydrodissection as the surgeon prefers.  Level II, Grade B). Percutaneous and open cholecystostomy Partial cholecystectomy CONVERSION TO OPEN
  67. 67.  Conversion should not be considered a complication and surgeons should have a low threshold for conversion; Decision to convert to an open procedure must be based on intraoperative assessment weighing the clarity of the anatomy & the surgeon’s skill/comfort in proceeding.
  68. 68. Use of the checklist reduced the rate of deaths andcomplications by more than 1/3 across all 8 pilothospitals. (Canada;India; Jordan;;NZ;;Philiphine ;Tnazania; Uk; ;USA)The rate of major inpatient complications dropped from11% to 7% after implementation of the checklist. atessentially no cost to the system..
  69. 69. CHECK YOUR TYRES BEFORE ANY JOURNE Y--
  70. 70.  Type A ;Cystic duct leaks or leaks from small ducts in the liver bed Type B ;Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts Type C; Transection without ligation of the aberrant right hepatic ducts Type D; Lateral injuries to major bile ducts Type E ;Subdivided as per Bismuth classification into E1 to E5
  71. 71.  E: injury to main duct (Bismuth)  E1 : Transection >2cm from confluence  E2 : Transection <2cm from confluence  E3 : Transection in hilum  E4 : Seperation of major ducts in hilum  E5: Type C plus injury in hilum
  72. 72. Co-mmunicate with patient and /or relatives
  73. 73. Bile Duct Injuries• How do you get Suspicion DURING OR—(intra operatively) • Atypical anatomy • “Accessory” duct • Unsuspected bile leakage • Abnormal cholangiogram
  74. 74.  Only 25-33% of injures are recognized intraoperatively 1. Expertise available ; Convert to Open Procedure and perform Cholangiography or vice versa (determine extent of injury) and accordingly --treat 2. Experitise not available ;Perform the cholangiogram laparoscopically with intent of referring patient (placement of drains); 1. Consult an experienced Hepatobiliary surgeon; 2. Quicker the repair, the better the outcome!!! Acute Management-do no more harm----Drain the bile- Sepsis control  Biliary catheter for decompression of biliary tract & Control of bile leaks  Percutaneous drainage (US/CT) of intraperitoneal bile collection
  75. 75.  The classic injury is when the CBD is mistaken for the cystic duct. Once the gallbladder has been removed, it is important to recognize that more than one structure has been injured, and the repair is complex. The goal of reconstruction is to avoid cholangitis, cirrhosis and stricture. In the presence of an injury, it is important not to panic, leave the patient well drained to control the leak, and refer to an experienced hepatobiliary surgeon. Finally, if an injury should occur, an experienced hepatobiliary surgeon should make the repair; this will greatly impact the rate of complications and the long-term success of the repair. Timing-- Data suggest that repairs performed early or after six weeks of the injury have better outcomes
  76. 76.  Patient presents with…clinically  Vague abdominal pain, nausea, fever, jaundice, vomiting Investigation Blood –lft.cbc;kft Ultrasonagraphy and CT (ductal dilatation and intra-abdominal collection) Cholangiogram  ERCP—biliary anatomy and assess the injury  PTC—define biliary anatomy proximal to injury  MRCP—noninvasive (can miss minor leaks)  HIDA scan-- MR angiography—vascular injuries
  77. 77.  HIDA – presence of active bile leak (physiologic
  78. 78. US/CT – detect bilomas + Per cut Drainage)
  79. 79.  Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree. Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site; may entail removal of retained stone or internal stenting +/- sphincterotomy Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D) Cessation of bile extravasation in 70-95% of cases w/in 7 days
  80. 80. POST-OPERATIVE BILE LEAKS & BILIARY FISTULASLimitations of ERCP—PTC –MRCP superior but non therupeticInability to visualise the biliary tree beyond the obstructionBilomas might need percutaneous drainage PTC
  81. 81. POST-Lap choleBILE LEAKS & BILIARYFISTULAS : ROLE OF ERCP=goodgastroenterologist is a help ; Fazal Khawaja, - Gastroenterology King Fahad Hospital Al Madina Al Munawarah.
  82. 82. Our experience (15yrs)Lap – Chole Related Bile leaks: Cystic duct stump 27(40%) Duct of Lushka 8(12%) Main Bile duct ( no luminal narrowing or obstruction) 5(7.5%) With main Bile duct injury 8(12%0 (convert to open = 6) MBD Inj + no leakage in ERC 19(28%)Total=67/171
  83. 83. ERCP helps in diagnosis and removes any doubts regarding possible major ductal injuries.The condition resolves spontaneously ] provided there is no distal obstruction; the processmay be hastened by the placement of a stent endoscopically.
  84. 84. Site of bile leaks:Duct of Lushka (DOL)
  85. 85. Bile leaks with luminalnarrowing of MBD
  86. 86. Careful flouroscopic observation of leakage point of originAn un-experienced & poorly equiped Endoscopist is thesurgeons worst enemyTo have a complication is bad luck but to mismanage it is Bad Medicine
  87. 87. Figure 2: MRCP revealing subhepatic and significant intra-abdominal bile collection from cystic duct leak. The CBD is not dilated. The patient was managed effectively with ERCPFigure 1: ERCP showing small CBD leak managed sphincterotomy. effectively by sphincterotomy
  88. 88. POST-OPERATIVE BILE LEAKS & BILIARY FISTULASLimitations of PTC and ERCPInability to visualise the biliary tree beyond the obstructionMRCp is diagnostic-shows both ends but is not therupeticBilomas might need percutaneous drainage ptc
  89. 89.  examine the source of bile leak Although bile may leak from an opening in the GB or the cystic duct, before that is presumed to be the case, BDI should be ruled out. Bile from GB is greenish yellow, thick, and viscid, whereas common bile duct (CBD) bile usually is bright yellow, thin, and watery. An IOC at this stage may delineate the anatomy and prevent any further injury to the bile duct. A BDI should also be suspected if a third tubular structure (after cystic duct and artery have been clipped and divided) is encountered in the Calot’s triangle. The “cystic duct” which was clipped and divided earlier may actually have been the CBD and the third structure now being encountered may be the common hepatic duct. If the BDI is recognized intraoperatively, the management depends on the nature of the duct injured, type of injury, and the expertise and experience of the surgeon
  90. 90.  Type-magnitude Expertise availbility Bile leak-Partial-Complete Bile-Obstruction ;clipping; Management differs
  91. 91.  The goal of surgical repair of the injured biliary tract is the restoration of a durable bile conduit, and the prevention of short- and long-term complications such as biliary fistula, intra-abdominal abscess, biliary stricture, recurrent cholangitis and secondary biliary cirrhosis. The ease of management, operative risk, and outcome of bile duct injuries vary considerably and are highly dependent on the type of injury and its location. For this, a classification bearing therapeutic and prognostic implications is needed.
  92. 92.  Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of the bile duct injury. Broad-spectrum antibiotics No need for an urgent laparotomy. Biliary reconstruction in the presence of peritonitis results a statistically worse outcome in patients. No need for urgent with reconstruction of the biliary tree. The inflammation, scar formation and development of fibrosis take several weeks to subside. Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.
  93. 93. Site of bile leaks:Cystic duct +Stent
  94. 94. Surgical management
  95. 95.  Injury to a major duct (right hepatic duct/CHD or CBD) has more serious consequences. In the event of this unfortunate incidence, further management including assessment would depend on the availability of expertise . Expertise Available In an ideal situation, a trained biliary surgeon with adequate experience in reconstructive biliary surgery should carry out the repair. The procedure should be converted to an open operation, and the injury should be repaired as detailed subsequently.
  96. 96.  A lateral/incomplete injury (involving partial circumference of the duct) may be repaired with fine (4-0/5-0) suture of vicryl/PDS. Some recommend the placement of a T tube as a stent. However, the placement of a T tube in an undilated normal size duct may be difficult and frustrating and could potentially aggravate the injury
  97. 97.  If the duct has been divided, it is important to assess if there is associated loss of a segment of the duct as happens in the classical lap cholecystectomy injury This happens when the CBD is first clipped and divided mistaking it for the cystic duct. CHD is then encountered and divided again. The ideal management of a complete transection of the bile duct is the restoration of the biliary enteric continuity with a Roux-en-Y hepaticojejunostomy.
  98. 98.  When the bile duct has been divided without excision of a segment, a primary end to end anastomosis of the cut ends of bile duct has been described. This procedure had fallen into disrepute after a report stating that almost half of such repairs developed into strictures that later required hepaticojejunostomy. . A distinct advantage of this procedure is that it maintains the normal biliary drainage into the duodenum and avoids the risk of reflux associated cholangitis and stricture following hepaticojejunostomy. Another advantage of the repair is that the stricture that might result is usually of a low variety (Bismuth Type 1 or 11). These are more easily repaired surgically in the event of failure of endoscopic and radiological intervention
  99. 99.  in such situations no attempt must be made to repair the injury. Repairs done by inexperienced surgeons are likely to fail. In addition, repair after a previous attempt even if done by an expert biliary surgeon is less likely to be successful The safest option (in the interest of both the patient and surgeon) is to irrigate the area with copious amounts of solution, observe and record the operative findings and place two large/wide bore (28 French) drain in the subhepatic fossa [ This will drain the bile from the injured duct and prevent the formation of a bilioma. Omentum if available may also be placed in the subhepatic fossa. This can be accomplished laparoscopically and there should be no need to convert to laparotomy. This will result in a controlled external biliary fistula, thus preventing peritoneal sepsis . Postoperatively an endoscopic papillotomy may be performed and a stent placed in the CBD in cases of partial injury to decompress the bile ducts The external biliary fistula may eventually close without any biliary obstruction in case of partial injury. In some cases especially those with complete injury, the biliary fistula may not close and repair will need to be performed using the undilated proximal ducts
  100. 100.  In the majority of cases (more than 60%), the biliary injury is unrecognized at laparoscopic cholecystectomy A high index of suspicion is essential to recognize biliary injury (leak or transaction of CBD) in the early postoperative period. the most common site of leak included cystic duct stump (78%), a peripheral right hepatic duct (Luschka 13%), and other sites like common bile duct and T tube insertion point (9%) [In a study of 2007 post ercp) The leak could either be low grade (LG) where the leak is noted only after the opacification of the intrahepatic biliary radicles with contrast following ERCP or a high-grade leak (HG) when the leak is observed fluoroscopically before intrahepatic duct opacification [ The later is considered more significant as the spillage of contrast occurs with minimal injection pressure and before the opacification of the ductal system. Patients with LG leak are effectively managed by sphincterotomy alone or placement of nasobiliary tube or stent placement, and it could achieve reduction in pressure gradient and allow closure of leak in >90% HG leak however would require stent placement with probably bridging the site of leak-like cystic duct stump leak. Decision of stent placement is however determined by the severity of leak rather than site of leak [12].
  101. 101.  If there is no bile leak, the patients may not have any symptoms and signs in the early postoperative period and may develop jaundice after an uneventful discharge from the hospital. Therefore, a follow-up visit approximately 1 to 2 weeks after cholecystectomy is desirable. Some BDIs especially ischaemic may present several months or even years after cholecystectomy . The management of injury detected after discharge from the hospital should be performed at a center with appropriate expertise outlined previously. The procedure of choice for repair of a major duct injury or stricture is a hepaticojejunostomy [.
  102. 102.  More often a biliary stricture develops (with dilated proximal ducts) which will require a hepaticojejunostomy. Placement of a tube into the proximal end of the divided duct to convert the BDI into a controlled external biliary fistula is attempted by some. The attempt to place a catheter into the injured nondilated proximal duct during the course of a laparoscopic cholecystectomy may, however, cause further injury to the CHD, particularly when performed by an inexperienced surgeon. Clipping of the divided duct is sometimes performed with intent to prevent bile leak and allow the injured duct to stricture resulting in the proximal duct dilatation which facilitates a hepaticojejunostomy . This is rarely successful because in the majority of cases the clipped or ligated ducts sloughs, thus causing the inevitable bile leak and resulting in the injury becoming even more proximal. Moreover, the clip (or ligature) also interferes with the blood supply and causes ischaemic injury
  103. 103.  Hepaticojejunostomy is preferred to choledochoduodenostomy as the latter is prone for complications due to reflux cholangitis [ref 5, 9, 33]. Hepaticojejunostomy with Roux-en-Y anastomosis reduces the tension of anastomosis and provides good blood supply and is the preferred option to treat duct transection injury [5, 9, 26–28, 33]. It is also the procedure of choice to treat duct defect and strictures. The outcome is significantly influenced by the surgical technique especially when the duct is not dilated [27, 28]. The outcome is better when one layer end to end anastomosis with 5-0 absorbable suture is carried out with the loop for bile drainage   longer than 50cms to avoid reflux and infection [5, 9, 26–28, 33]. The dead tissue at the end of the duct should be debrided [26, 28]. Some would place a temporary stent tube through the area of reconstruction when the duct is small. The tube helps to perform the anastomosis while permitting to perform cholangiography to check in a week or so, and it may serve as a drain if the anastomosis is temporarily leaking. The use of a transanastomotic stent is, however, debatable [25, 26].
  104. 104. Side to side –anastomosis –bismuth II or III
  105. 105. Outcome results Why? Results by an expert- and results by an routine
  106. 106.  The best outcomes  Early repair (72 hours after LC-BDI)  late repair (>6 weeks after LC-BDI). A minor comment is that an interval between 0 and 72 hours after LC- BDI has an unclear meaning:  0 hours suggests intraoperative repair,  Most important, within the intermediate timing of repair (from 72 hours to 6 weeks after LC-BDI), a critical distinction should be made between the presence of a clean surgical field (ie, complete common bile duct stenosis with obstructive jaundice, without bile spillage) and a field that is inflamed or infected by bile.  We believe that in the former case, surgical repair would occur in an ideal condition within 2 weeks following LC-BDI, . .
  107. 107.  EXPERT VS NORMAL ; Successf rate when Surgery performed by/at  Primary surgeon =35%  Specialized Expert( hepatobiliary surgeon)=>90 %, (John Hopkins Group –99 ) Timing– of Repairs ;Early or after 6 weeks of the injury have better outcomes than those repaired in the intermediate period. Contirb factors for outcome- active peritonitis , assoctd vascular injury, the level of injury at or above the biliary bifurcation, and no.of previous operations
  108. 108. Suggested flow diagram for patients with suspected bile duct injuryafter laparoscopic cholecystectomy [3].Manouras et al. Journal of Medical Case Reports 2009 3:44doi:10.1186/1752-1947-3-44
  109. 109.  Timing of diagnosis;Expertise availability; SEPSIS ETC Endoscopic stenting for strictures  T-tube placement for minor lacerations  Primary duct-to-duct repair only if tension free anastomosis available  Biliary anastomosis with jejunal loop for major excisional injuries
  110. 110. Safe Surgery Saves Lives Frequently
  111. 111. An error during gallbladder surgery ) is a common source ofmedical malpractice claims, largely because this is a commonform of surgery.    Most malpractice claims from gallbladdersurgery occur when a surgeon does not know where the biliaryducts are on a patient and cuts where the surgeon should not becutting.  Experience vs carelessness Can an experienced surgeon using ordinary care cut this common bile duct?  The answer is almost certainly yes.  “it is the same surgeons who are “frequent flyers” in malpractice claims involving common bile duct injuries.”- malpractice lawyer
  112. 112.  Another common defense is the “patient had unusual anatomy” or “he/she was too fat to be able to see” defenses.   These are slightly more saleable defenses in some cases but usually it is a reflex surgeons being sued for malpractice use in every case.  Typically, there is nothing to suggest unusual anatomy and no explanation as to why the doctor did not try to use a cholangiogram (which malpractice cases rarely involve) to figure out what belonged where.
  113. 113.  Professional negligence is defined as absence of reasonable care and skill or willful negligence of a medical practitioner in the treatment of a patient, which causes bodily injury or death of patient. A doctor is not liable if he exercises reasonable skill and care, provided that his judgment conforms to accepted medical practice and does not result in an error of omission. The doctor cannot be sued for professional negligence, when statistics show that accepted methods of treatment have been employed on the patient and that the risk and injury which resulted are of a kind that may occur even though reasonable care has been taken. Present position----The usual misperception error underlying laparoscopic bile duct injuries does not meet the defining criteria of medical negligence
  114. 114.  Bile duct injuries are a major complication of both open cholecystectomy and LC. It can have devastating effects, turning the individual into a "biliary cripple". They mainly result from anatomical anomalies ‘local factors and errors of human judgment and are thus preventable to some extent. The costs are reduced and outcome improved if these injuries are diagnosed early (during operation or the early postoperative period). And handled by experienced biliary surgeon;Int rRadiologist ;;endoscopist (ERCP)Team) Adding the experience gained from open cholecystectomy on the one hand and the advantages of certification and revalidation in LC to improve surgical techniques ;modifications in terms of visualization and magnification on the other, will help in reducing the incidence of such complications.
  115. 115. What model should exist in healthcare?  It is argued that not one model of accountability fits all of health care.  Health care is too complicated, with too many parties, with too many complex relationships for just one model.  Stratified model of accountability? Tailored to local conditions…. (Emanuel & Emanuel, 1995)
  116. 116. “Despite numerous publications on this topic, there is no simpleQUOTE OF THE DAY set of rules that inexperienced surgeons can follow in order to avoid such a complication. When it comes to experienced surgeons, we all know it is hard to teach humility.”Ist and last Message=“first do no harm ” -- e very student in medical school takes
  117. 117.  "There is no moving creature on earth but its sustenance depends on God: He knows the time and place of its definite abode and its Temporary deposit: All is in a clear Record"……… Quran, Hud, 11: 6 The Bestower of Provision , Allah(SWT), the Almighty says: "Surely Allah is the Bestower of provision, Lord of Power, the Almighty".Noble Quran (52:58) I am the Boss- I am the BEST –dnt know … Why This arrogance?.....in this world ------
  118. 118. Background to Safe Surgery SavesLives
  119. 119.  The author is indebited to those contributors whose pictures have been shared with readers here for purely academic purposes to benefit processionals and patients(humanity at large ……..) and there is no conflict of interest directly or indirectly except pure academic reminders in bringing this material-to help prevention of this complication ---and in case anyone has his/her objection –the author will immediately delete that ….material-- thanx

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  • rajeshreddykrv

    Nov. 25, 2013
  • mtepes

    Oct. 29, 2014
  • SacdiyaCqaadir

    Dec. 15, 2017

Bile duct injuries (BDI) take place in a wide spectrum of clinical settings. The mechanisms of injury, previous attempts of repair, surgical risk and general health status importantly influence the diagnostic and therapeutic decision-making pathway of every single case. A multidisciplinary approach including hepatobiliary surgeon , endoscopy and interventional radiology specialists is required to properly manage this complex disease-the best treatment is prevention

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