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Injury During Laparoscopic Gallbladder Surgery

Injury During Laparoscopic Gallbladder Surgical

An injury during a laparoscopic gallbladder surgery can occur.

Understanding Gallstones

The gallbladder (or cholecyst or gall bladder) is a pear-shaped organ located in the right upper abdomen below the liver.1

The gallbladder aids in the digestive process storing bile that is produced by the liver until it is needed by the body. Bile is a liquid that helps the body digest fats. When the liquid contains too much cholesterol, bile salts, or bilirubin, it can harden into stone-like substances called “gallstones.”2

Gallstones can occur anywhere in the biliary tract, including the gallbladder and the common bile duct. Gallstones can vary in size from as small as a grain of sand to as large as a golf ball. Many times people who have gallstones experience no symptoms at all. These are called “silent stones,” and usually no treatment is recommended.3

The American Gastroenterological Association cites the most common symptom of gallstone disease as “severe steady pain in the upper abdomen or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder. Sometimes patients also have vomiting or sweating. Attacks of gallstone pain may be separated by weeks, months or even years.”4

Gallstones affect 10 percent to 15 percent of the population of the United States, or well over 25 million people. There are about one million new cases of gallstones reported every year in this country alone. Approximately one-quarter of these require treatment.5 Surgical removal of the gallbladder is the preferred treatment for symptomatic gallstones.6

Symptoms of Gallstones

Gallstones do not always produce signs or symptoms. When symptoms do occur, this is called a “gallbladder attack” because the symptoms occur abruptly. A gallbladder attack may be as short as several minutes or last as long as several hours. The symptoms are caused when the gallstones move into the bile ducts and create a blockage or obstruction. As pressure increases in the gallbladder, one or more symptoms may occur.7

  • The symptoms of a gallbladder attack may include one or more of the following:
  • Sudden and rapidly intensifying pain in the upper right portion of your abdomen
  • Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
  • Back pain between your shoulder blades
  • Pain in your right shoulder8
Medical professionals recommend that you contact your doctor if you think you have experienced a gallbladder attack. Many times these attacks pass as gallstones move and the pressure is relieved, but it is possible for your gallbladder to become infected and rupture if a blockage remains. You should contact your doctor whenever you experience a gallbladder attack, and seek immediately medical attention if you experience any of the following symptoms:
  • Prolonged pain for more than 5 hours
  • Nausea or vomiting
  • Low-grade fever or chills
  • Yellowish color of the skin or of the whites of the eyes
  • Clay-colored stools9

Complications of Gallstones

Generally, gallstone pain may result from blockage of the cystic duct by a stone. When the blockage persists for more than several hours, the gallbladder may become inflamed. This is a condition known as acute cholecystitis. Cholecystitis can cause fever, prolonged pain, and even eventually infection of the gallbladder. Your doctor will usually recommend that you be hospitalized for observation, treatment with antibiotics and pain medications, and for possible surgical removal of the gallbladder by a procedure called a cholecystectomy. More serious complications of gallstones may occur if the gallstone passes out of the cystic duct and into and down the common bile duct. This can cause a serious bile duct infection or inflammation of the pancreas. Either condition is extremely hazardous to your health.10

The obstruction of the common bile duct is called choledocholithiasis. This is a serious condition that can cause jaundice and liver cell damage. This condition requires emergency medical treatment by a procedure known as an endoscopic retrograde cholangiopancreatography (ERCP) or by surgery intervention.11 Obstruction of the biliary tract can cause jaundice. While obstruction of the outlet of the pancreatic exocrine system can cause pancreatitis.12

Medical professionals recommend that you immediately contact your doctor if you experience any signs or symptoms associated with gallstones and immediately call 911 if you have any symptoms of a serious gallstone complication such as intense abdominal pain, yellowing of your skin and whites of your eyes, or are experiencing a fever.
Non-Surgical Treatment Options for Symptomatic Gallstones

There are non-surgical treatments for persons who experience gallstone attacks, but they are considered by medical professional to have disadvantages over surgery since there are not cures in most cases. Gallstones return in approximately have of the cases where people were treated with non-surgical methods. These non-surgical treatments may also require the taking medicine for long periods of time while the patient continues to experience painful symptoms.13

Alternatives to Surgery for Symptomatic Gallstones

Oral Dissolution Therapy

Oral dissolution therapy involves the taking of oral drugs that can sometimes dissolve the gallstones. The drug uses the chemical ursodiol or chenodiol. This medicine thins the bile and dissolves the gallstones. However, only small stones composed of cholesterol dissolve rapidly and completely.14 Oral dissolution therapy can take many months and does not necessarily cure the disease. When the treatment stops it is possible for new gallstones to develop.15 Generally, medications for gallstone treatment are typically reserved for people who can’t undergo surgery.16

Extracorporeal Shockwave Lithotripsy (ESWL)

Extracorporeal shockwave lithotripsy (ESWL) uses shock waves to break a gallstone into small pieces so they can pass through the common bile duct and into the small intestine. This treatment option may only be effective with certain kinds of gallstones and may be combined with oral dissolution therapy.17

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that uses an endoscopy and fluoroscopy so as to allow the physician to see inside the patient’s stomach and duodenum. Dyes are injected into the biliary ducts and pancreas so they can be easily seen on x-rays.18 This procedure and be used to find and remove stones in the common bile duct.19

Contact Dissolution Therapy

Contact dissolution therapy is an experimental treatment that injects a chemical directly into the gallbladder in order to dissolve the gallstones more quickly. Again, this therapy is only effective on cholesterol-based gallstones. Tests are ongoing to determine the safety and effectiveness of this procedure. Generally, medications for gallstone treatment are typically reserved for people who can’t undergo surgery.20
Surgical Treatment for Symptomatic Gallstones

There are two surgical procedures used to treat symptomatic gallstones. Both procedures remove the gallbladder surgically. The traditional surgical procedure, and the prevailing one prior to the mid-1990s’, was the open cholecystectomy. This is an invasive procedure requiring a fairly large surgical scar and a longer recover period due in part to the fact that the abdominal muscles must be cut to gain access to the abdominal cavity. Today the preferred procedure is the laparoscopic cholecystectomy. This is a minimally invasive surgical procedure that usually requires a shorter recovery time and only several small surgical scars.

The abdominal cavity is the space bounded by the vertebrae, abdominal muscles, diaphragm and pelvic floor. The organs of the abdominal cavity include the stomach, liver, gallbladder, spleen, pancreas, small intestine, large intestine, and kidneys.21

The abdominal cavity includes the intraperitoneal space and the retroperitoneal space. The intraperitoneal space is wrapped in peritoneum. The peritoneum is a protective membrane that lines the lines the intraperitoneal space of the abdominal cavity. There are two lawyers of the peritoneum. The outer layer is called the parietal peritoneum and is attached to the abdominal wall. The inner layer is called the visceral peritoneum and is wrapped around the internal organs that are located inside the intraperitoneal cavity. The space between the two layers is called the peritoneal cavity, and is filled with a small amount serous fluid that allows the two layers to slide freely over each other.22

The gallbladder is a hollow organ that sits in a concavity of the liver known as the gallbladder fossa.23 The gallbladder fossa is defined as “a depression lodging the gallbladder on the undersurface of the liver anteriorly, between the quadrate and the right lobes.”24

Some organs and structures are located behind the peritoneum, in an area called the retroperitoneal. The structures of the primarily retroperitoneal include the adrenal glands, kidneys, ureter, bladder, aorta, inferior vena cava, part of the esophagus, and part of the rectum.25

Open Cholecystectomy

For more than 100 years the surgery of choice for the treatment of gallstones was the open cholecystectomy, whereby the surgeon opens the abdominal cavity and removes the gallbladder. This surgery was, and still is, considered a safe and effective surgical procedure for the treatment of gallstones. This traditional open surgical procedure, however, requires the surgeon to make a 10-18 cm (4-7 inch) incision on the patient’s abdomen, and usually requires an overnight hospital admission and a convalescence period of several weeks.26

Laparoscopic Cholecystectomy

Today, laparoscopic cholecystectomy or gallbladder surgery is the procedure of choice for the treatment for gallstones.27

This procedure is less invasive then the traditional open surgery, can sometimes be done on an outpatient basis, only produces several small surgical scars, and requires a shorter convalescence time. During a laparoscopic cholecystectomy, the surgeon will remove the gallbladder with a laparoscope and other surgical instruments. A laparoscope is a thin metal tube with a light and camera attached.28

The patient is first anesthetized and placed in the supine position. The surgeon will then make several small incisions in the abdomen, including one in the umbilicus. These incisions or openings will provide ports for the insertion of the surgical instruments into the abdominal cavity. The abdominal cavity is then inflated with carbon dioxide to create a viable surgical working area. The surgeon views the entire procedure on monitors. The surgeon must then identify gallbladder fundus. The gallbladder fundus is the part of the gallbladder that is farthest from the cystic duct. Once the gallbladder fundus is identified, the surgeon grasps, and retracts it superiorly. With a second grasper, the gallbladder infundibulum (or funnel-shaped part of the organ) is retracted laterally to expose and open Calot’s Triangle.29

The Calot’s Triangle (or hepatobiliary triangle, or cystohepatic triangle) is named for Jean-François Calot who first described this anatomy in 1891. The Calot’s Triangle is “the anatomic space bordered by the common hepatic duct medially, the cystic duct inferiorly and the cystic artery (liver) superiorly.” Also, the cystic artery usually passes through the triangle.30 The cystic artery is a vital anatomical structure that should be properly identified by the surgeon and should not be insulted or damaged during the operation.

Once the Calot’s Triangle is identified, the surgeon will perform dissection to clear the peritoneal covering and obtain a clear view of the underlying structures. At this point, the surgeon will attempt to identify cystic duct and cystic artery. Once these structures are properly identified, the surgeon will clip them with titanium clips and separate them. Only then can the gallbladder be dissected away from the liver bed and removed through a portal. 31

Risks Associated with Laparoscopic Cholecystectomy

As with any surgical procedure there are certain risks. Some of the risks associated with laparoscopic cholecystectomy (gallbladder surgery or gallstone surgery) are noted to be the following:

  • Risks associated with general anesthesia
  • Infection
  • Bleeding
  • Leakage of bile the liver or a duct
  • Damage to the cystic artery
  • Damage to the common bile duct
  • Damage to other nearby organs32
Deviation from Accepted Surgical Care

If there is any doubt as to the identity of any of the structures or organs, the surgeon should immediately convert the procedure to an open procedure before performing any clipping or dissection of the cystic duct and cystic artery for the safety of the patient. If a vital organ or structure is clip or severed, such as the common bile duct, a serious complication will result to the patient. The laparoscopic procedure requires meticulous skill and training on the part of the surgeon. In some surgeries it may be difficult to correctly identify certain structures laparoscopically due to anatomic anomalies. In such circumstances, the open procedure provides a better view of the surgical field and the structures involved. Intra-operative consultations may also be obtained as well as special tests order such as an intra-operative endoscopic retrograde cholangiopancreatography to help correctly identify the structures. Other times, the surgeon may simply misidentify a structure, such as confusing the cystic duct for the common bile duct. This could result from a lack of experience or training. Whatever the reason, a gross error such as this may cause serious adverse consequences for the patient.

Although, laparoscopic cholecystectomy is generally accepted as a safe and effective surgical procedure, it has been noted that the outcome or result of the gallbladder surgery “is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure.”33

Injury to the Common Bile Duct During Laparoscopic Gallbladder Surgical

Generally, damage or insult to the common bile duct is a risk of laparoscopic gallbladder surgery. However, this injury is not an acceptable risk or an adequate defense in a surgical error or malpractice case. This common bile duct injury generally arises solely due to the inexperience or incompetence of the surgeon. The failure to properly visualize and correctly identify all of the vital structures during the surgery prior to clipping and dissection is surgical malpractice. This injury, generally, does not and should not occur when the proper surgical techniques are utilized.

Damage to the common bile duct, may result in serious complications and require corrective surgery by a biliary specialist.

Personal Injury Lawyer

If you or a loved one has sustained an injury to the common bile duct, cystic artery, or other vital organ during a New York laparoscopic gallbladder surgery, you may be entitled to compensation for your pain and suffering and other economic losses. Speak to a New York personal injury lawyer as soon as possible.

  • The foregoing is for informational purposes only. It is not intended as medical advice or opinion, nor is it intended as legal advice or opinion. Always speak to your doctor for medical advice or opinions. If you are experiencing a medical emergency, call 911 immediately.

References:

  1. NIH Gallstones (www.digestive.niddk.nih.gov/ddiseases/pubs/gallstones/)
  2. Ibid.
  3. https://www.gastro.org/patient-center/digestive-conditions/gallstones
  4. Ibid. The American Gastroenterological Association (AGA) was founded in 1897. The AGA includes 17,000 members from around the globe. These members are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization.
  5. https://en.wikipedia.org/wiki/Gallstone
  6. https://www.gastro.org/patient-center/digestive-conditions/gallstones
  7. NIH (www.digestive.niddk.nih.gov/ddiseases/pubs/gallstones/#1)
  8. https://www.mayoclinic.com/health/gallstones/DS00165/DSECTION=symptoms
  9. NIH (www.digestive.niddk.nih.gov/ddiseases/pubs/gallstones/#1)
  10. https://www.gastro.org/patient-center/digestive-conditions/gallstones
  11. https://en.wikipedia.org/wiki/Choledocholithiasis
  12. https://en.wikipedia.org/wiki/Gallstone
  13. https://www.ehealthmd.com/library/gallstones/GS_treatment.html#nonsurg
  14. https://www.gastro.org/patient-center/digestive-conditions/gallstones
  15. www.ehealthmd.com/library/gallstones/GS_treatment.html#nonsurg
  16. https://www.mayoclinic.com/health/gallstones/DS00165/DSECTION=treatments-and-drugs
  17. www.ehealthmd.com/library/gallstones/GS_treatment.html#nonsurg
  18. http://en.wikipedia.org/wiki/Endoscopic_retrograde_cholangiopancreatography
  19. https://www.gastro.org/patient-center/digestive-conditions/gallstones
  20. https://www.mayoclinic.com/health/gallstones/DS00165/DSECTION=treatments-and-drugs
  21. https://en.wikipedia.org/wiki/Abdominal_cavity
  22. https://en.wikipedia.org/wiki/Peritoneum
  23. https://en.wikipedia.org/wiki/Gallbladder
  24. https://www.medilexicon.com/medicaldictionary.php?t=34991
  25. https://en.wikipedia.org/wiki/Retroperitoneum
  26. https://www.uofmhealth.org/health-library/hw106860#hw106862
  27. https://en.wikipedia.org/wiki/Cholecystectomy
  28. https://www.uofmhealth.org/health-library/hw106860#hw106862
  29. https://en.wikipedia.org/wiki/Cholecystectomy
  30. https://en.wikipedia.org/wiki/Calot’s_Triangle
  31. https://en.wikipedia.org/wiki/Cholecystectomy
  32. https://www.uofmhealth.org/health-library/hw106860#hw106862
  33. https://en.wikipedia.org/wiki/Laparoscopic_cholecystectomy#Procedural_Risks_and_Complications
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