PURPOSE: Bile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population. METHODS: In the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018-2021. In this cohort, we examined the incidence of major BDI following the reconstruction of the biliary tract and other complications. RESULTS: A total of 76,345 elective cholecystectomies were performed during the study period, and 186 major BDIs were registered (0.24%). Most elective cholecystectomies were performed laparoscopically (84.7%), with the remaining open (15.3%). The incidence of BDI was higher in the open surgery group (150 BDI/11700 cases/1.28%) than in laparoscopic cholecystectomy (36 BDI/64645 cases/0.06%). Furthermore, the total hospital stays with BDI after reconstruction was 13.6 days. However, the majority of laparoscopic elective cholecystectomies (57,914, 89.6%) were safe and standard procedures with no complications. CONCLUSION: Our study corroborates the findings of previous nationwide studies. Therefore, though laparoscopic cholecystectomy is reliable, the risks of BDI cannot be eliminated.

Department of Surgery 1 Faculty of Medicine and Dentistry University Hospital Olomouc and Palacký University Olomouc Zdravotníků 248 7 CZ 77900 Olomouc Czech Republic

Faculty of Medicine Institute of Biostatistics and Analyses Masaryk University Kamenice 753 5 CZ 62500 Brno Czech Republic

Institute of Health Information and Statistics of the Czech Republic Palackého náměstí 4 CZ 12801 Prague Czech Republic

See more in PubMed

Aguayo E, Dobaria V, Nakhla M, Seo YJ, Hadaya J, Cho NY, Sareh S, Sanaiha Y, Benharash P. National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy. Surgery. 2020;168(4):625–630. doi: 10.1016/j.surg.2020.06.018. PubMed DOI

Tschuor C, Lyman WB, Passeri M, Salibi PN, Baimas-George M, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study. Int J Med Robot. 2021 doi: 10.1002/rcs.2312. PubMed DOI

Pesce A, Portale TR, Minutolo V, Scilletta R, Li Destri G, Puleo S. Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients. Dig Surg. 2012;29(4):310–314. doi: 10.1159/000341660. PubMed DOI

Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg. 2001;234(4):549–558. doi: 10.1097/00000658-200110000-00014. PubMed DOI PMC

Carroll BJ, Birth M, Phillips EH. Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc. 1998;12(4):310–313. doi: 10.1007/s004649900660. PubMed DOI

van de Graaf FW, Zaïmi I, Stassen LPS, Lange JF. Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention. Int J Surg. 2018;60:164–172. doi: 10.1016/j.ijsu.2018.11.006. PubMed DOI

Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment. World J Surg. 2001;25(10):1241–1244. doi: 10.1007/s00268-001-0102-8. PubMed DOI

Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180(1):101–125. PubMed

McMahon AJ, Fullarton G, Baxter JN, O'Dwyer PJ. Bile duct injury and bile leakage in laparoscopic cholecystectomy. Br J Surg. 1995;82(3):307–313. doi: 10.1002/bjs.1800820308. PubMed DOI

Bergman JJ, van den Brink GR, Rauws EA, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut. 1996;38(1):141–147. doi: 10.1136/gut.38.1.141. PubMed DOI PMC

Neuhaus P, Schmidt SC, Hintze RE, et al. Einteilung und Behandlung von Gallengangverletzungen nach laparoskopischer Cholecystektomie [Classification and treatment of bile duct injuries after laparoscopic cholecystectomy] Chirurg. 2000;71(2):166–173. doi: 10.1007/s001040051033. PubMed DOI

Csendes A, Navarrete C, Burdiles P, Yarmuch J. Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management. World J Surg. 2001;25(10):1346–1351. doi: 10.1007/s00268-001-0121-5. PubMed DOI

Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460–469. doi: 10.1097/01.SLA.0000060680.92690.E9. PubMed DOI PMC

Bektas H, Schrem H, Winny M, Klempnauer J. Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems. Br J Surg. 2007;94(9):1119–1127. doi: 10.1002/bjs.5752. PubMed DOI

Lau WY, Lai EC. Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int. 2007;6(5):459–463. PubMed

Fingerhut A, Dziri C, Garden OJ, et al. ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy. Surg Endosc. 2013;27(12):4608–4619. doi: 10.1007/s00464-013-3081-6. PubMed DOI

Ismael HN, Cox S, Cooper A, Narula N, Aloia T. The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: a multi-institutional analysis of risk factors and outcomes using NSQIP. HPB (Oxford) 2017;19(4):352–358. doi: 10.1016/j.hpb.2016.12.004. PubMed DOI

Stewart L. Iatrogenic biliary injuries: identification, classification, and management. Surg Clin North Am. 2014;94(2):297–310. doi: 10.1016/j.suc.2014.01.008. PubMed DOI

Palmucci S, Mauro LA, La Scola S, Incarbone S, Bonanno G, Milone P, Russo A, Ettorre GC. Magnetic resonance cholangiopancreatography and contrast-enhanced magnetic resonance cholangiopancreatography versus endoscopic ultrasonography in the diagnosis of extrahepatic biliary pathology. Radiol Med. 2010;115(5):732–746. doi: 10.1007/s11547-010-0526-z. PubMed DOI

Rainio M, Lindström O, Udd M, Haapamäki C, Nordin A, Kylänpää L. Endoscopic therapy of biliary injury after cholecystectomy. Dig Dis Sci. 2018;63(2):474–480. doi: 10.1007/s10620-017-4768-7. PubMed DOI

Renz BW, Bösch F, Angele MK. Bile duct injury after cholecystectomy: surgical therapy. Visc Med. 2017;33(3):184–190. doi: 10.1159/000471818. PubMed DOI PMC

Maddah G, Rajabi Mashhadi MT, Parvizi Mashhadi M, Nooghabi MJ, Hassanpour M, Abdollahi A. Iatrogenic injuries of the extrahepatic biliary system. J Surg Res. 2017;213:215–221. doi: 10.1016/j.jss.2015.11.032. PubMed DOI

Manatakis DK, Antonopoulou MI, Tasis N, Agalianos C, Tsouknidas I, Korkolis DP, Dervenis C. Critical view of safety in laparoscopic cholecystectomy: A systematic review of current evidence and future perspectives. World J Surg. 2022 doi: 10.1007/s00268-022-06842-0. PubMed DOI

Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, Fuks D, Giménez ME, Goumard C, Kaneko H, Memeo R, Resende A, Scatton O, Schneck AS, Soubrane O, Tanabe M, van den Bos J, Weiss H, Yamamoto M, Marescaux J, Pessaux P. IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci. 2017;24(11):603–615. doi: 10.1002/jhbp.491. PubMed DOI

de'Angelis N, Catena F, Memeo R et al (2021) 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 16(1):30. 10.1186/s13017-021-00369-w PubMed PMC

Barrett M, Asbun HJ, Chien HL, Brunt LM, Telem DA. Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surg Endosc. 2018;32(4):1683–1688. doi: 10.1007/s00464-017-5847-8. PubMed DOI

Rystedt J, Lindell G, Montgomery A. Bile duct injuries associated with 55,134 cholecystectomies: treatment and outcome from a national perspective. World J Surg. 2016;40(1):73–80. doi: 10.1007/s00268-015-3281-4. PubMed DOI

Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos) J Hepatobiliary Pancreat Sci. 2018;25(1):73–86. doi: 10.1002/jhbp.517. PubMed DOI

Díaz-Martínez J, Chapa-Azuela O, Roldan-García JA, Flores-Rangel GA. Bile duct injuries after cholecystectomy, analysis of constant risk. Ann Hepatobiliary Pancreat Surg. 2020;24(2):150–155. doi: 10.14701/ahbps.2020.24.2.150. PubMed DOI PMC

Nawacki Ł, Kozłowska-Geller M, Wawszczak-Kasza M, Klusek J, Znamirowski P, Głuszek S. Iatrogenic injury of biliary tree-single-centre experience. Int J Environ Res Public Health. 2022;20(1):781. doi: 10.3390/ijerph20010781. PubMed DOI PMC

Roy PG, Soonawalla ZF, Grant HW. Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy. HPB (Oxford) 2009;11(2):130–134. doi: 10.1111/j.1477-2574.2008.00023.x. PubMed DOI PMC

Oliverius M, Gürlich R. Surgery of iatrogenic bile duct injuries. Chirurgie iatrogenních poranění žlučových cest. Rozhl Chir. 2022;101(9):421–427. doi: 10.33699/PIS.2022.101.9.421-427. PubMed DOI

Sváb J, Pesková M, Krska Z, Gürlich R, Kasalický M. Prevence, diagnostika a chirurgická lécba poranĕní zlucovodů bĕhem laparoskopické cholecystektomie. Lécení poranĕní papily v důsledku invazivní endoskopie. Cast 2.--Chirurgická lécba poranĕní zlucovodů [Prevention, diagnosis and surgical treatment of injuries of the biliary tract during laparoscopic cholecystectomy. Treatment of papilla injuries caused by invasive endoscopy. Part 2. Surgical treatment of biliary tract injuries] Rozhl Chir. 2005;84(4):182–190. PubMed

Donkervoort SC, Kortram K, Dijksman LM, Boermeester MA, van Ramshorst B, Boerma D. Anticipation of complications after laparoscopic cholecystectomy: prediction of individual outcome. Surg Endosc. 2016;30(12):5388–5394. doi: 10.1007/s00464-016-4895-9. PubMed DOI

Treska V, Skalický T, Safránek J, Kreuzberg B. Poranĕní zlucových cest pri cholecystektomii [Injuries to the biliary tract during cholecystectomy] Rozhl Chir. 2005;84(1):13–18. PubMed

Hobbs MS, Mai Q, Knuiman MW, Fletcher DR, Ridout SC. Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy. Br J Surg. 2006;93(7):844–853. doi: 10.1002/bjs.5333. PubMed DOI

Hibi T, Iwashita Y, Ohyama T, et al. The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan. J Hepatobiliary Pancreat Sci. 2017;24(1):24–32. doi: 10.1002/jhbp.417. PubMed DOI

Sanjay P, Kulli C, Polignano FM, Tait IS. Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland. Ann R Coll Surg Engl. 2010;92(4):302–306. doi: 10.1308/003588410X12628812458617. PubMed DOI PMC

Bogacki P, Krzak J, Gotfryd-Bugajska K, Szura M. Evaluation of the usefulness of the SAGES Safe Cholecystectomy Program from the viewpoint of the European surgeon. Wideochir Inne Tech Maloinwazyjne. 2020;15(1):80–86. doi: 10.5114/wiitm.2019.83297. PubMed DOI PMC

Strasberg SM, Brunt LM. Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 2010;211(1):132–138. doi: 10.1016/j.jamcollsurg.2010.02.053. PubMed DOI

Kurahashi S, Komatsu S, Matsumura T, et al. A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy. Surg Endosc. 2020;34(7):2904–2910. doi: 10.1007/s00464-020-07610-8. PubMed DOI

Reitano E, de’Angelis N, Schembari E, et al. Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review. ANZ J Surg. 2021;91(9):E554–E560. doi: 10.1111/ans.17021. PubMed DOI PMC

Nijssen MA, Schreinemakers JM, van der Schelling GP, Crolla RM, Rijken AM. Improving Critical View of Safety in Laparoscopic Cholecystectomy by Teaching Interventions. J Surg Educ. 2016;73(3):442–447. doi: 10.1016/j.jsurg.2015.11.015. PubMed DOI

Nakazato T, Su B, Novak S, Deal SB, Kuchta K, Ujiki M. Improving attainment of the critical view of safety during laparoscopic cholecystectomy. Surg Endosc. 2020;34(9):4115–4123. doi: 10.1007/s00464-019-07178-y. PubMed DOI

van de Graaf FW, van den Bos J, Stassen LPS, Lange JF. Lacunar implementation of the critical view of safety technique for laparoscopic cholecystectomy: Results of a nationwide survey. Surgery. 2018;S0039–6060(18):30032–30041. doi: 10.1016/j.surg.2018.01.016. PubMed DOI