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Complications of laparoscopic cholecystectomy

Complications of laparoscopic cholecystectomy
Literature review current through: Jan 2024.
This topic last updated: Jan 17, 2023.

INTRODUCTION — Laparoscopic cholecystectomy is now the standard of care for gallbladder removal. Approximately 750,000 laparoscopic cholecystectomies are performed annually in the United States (accounting for roughly 90 percent of all cholecystectomies) with an overall serious complication rate that has decreased since the early days [1-4].

At the same time, the complication rate of open cholecystectomy has increased and the complications have become more severe [5] with the worst injuries to the bile duct, hepatic artery, or portal vein occurring after conversion from laparoscopic to open cholecystectomy [6,7]. This is because open cholecystectomy is now reserved for the most complicated and challenging cases, and there is also overall declining experience with open surgery [8]. (See "Open cholecystectomy".)

This topic review will discuss complications that are specifically related to or more commonly encountered with the laparoscopic procedure. The management of acute cholecystitis, indications and surgical techniques for laparoscopic cholecystectomy, common bile duct exploration, and repair of common bile duct injuries are discussed elsewhere in detail. (See "Treatment of acute calculous cholecystitis" and "Laparoscopic cholecystectomy" and "Endoscopic management of postcholecystectomy biliary complications" and "Surgical common bile duct exploration" and "Repair of common bile duct injuries".)

Other adverse outcomes, such as retained common bile duct stones, postcholecystectomy syndromes, and misdiagnoses (sphincter of Oddi dysfunction) occur with the same frequency with both laparoscopic and open cholecystectomy and will not be discussed here. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Laparoscopic cholecystectomy", section on 'Postcholecystectomy syndrome'.)

Several complications of laparoscopic cholecystectomy are primarily managed endoscopically. The endoscopic management of biliary complications is discussed elsewhere. (See "Endoscopic management of postcholecystectomy biliary complications".)

INCIDENCE — In a study that combined the data from seven studies with a total of 8856 laparoscopic cholecystectomies, serious complications occurred in 2.6 percent [9].

A combined review of eight studies of laparoscopic cholecystectomies reported the following types and frequencies of major complications: bleeding (0.11 to 1.97 percent), abscess (0.14 to 0.3 percent), bile leak (0.3 to 0.9 percent), biliary injury (0.26 to 0.6 percent), and bowel injury (0.14 to 0.35 percent) [10].

A 1993 survey of 77,604 cases from 4292 United States (US) hospitals reported a major complication rate of 1.2 percent, including bile injury (0.6 percent), bile leak (0.3 percent), and bowel (0.14 percent) and vascular injury (0.25 percent) [11].

In 40 series of laparoscopic cholecystectomy in the US from 1989 to 1995, including a total of 114,005 cases, 561 major bile duct injuries (0.50 percent) and 401 bile leaks from the cystic duct or liver bed (0.38 percent) were reported [12].

More contemporary literature has reported major bile duct injury in 0.1 and 0.3 percent of elective and emergency laparoscopic cholecystectomies, respectively. All types of bile duct injuries occurred in 0.4 and 0.8 percent of elective and emergency settings, respectively [13].

The rate of wound infections and surgical site infections is lower with the laparoscopic approach than with the open approach, but there is no advantage in terms of intra-abdominal abscess formation [14].

RISK FACTORS — Serious complications that occur with laparoscopic cholecystectomy, including bile duct injury, bile leaks, bleeding, and bowel injury, can be related to patient selection, surgical experience, and the technical constraints that are inherent to the minimally invasive approach [2,15-20]. Additional factors include:

Anatomic factors – Numerous anatomical variants pose major threats to safe cholecystectomy, including short cystic duct, cystic duct parallel to the common bile duct, hepatocystic duct, accessory cyst duct, duct of Luschka, and replaced right hepatic artery [21].

Disease factors - Serious complications are more likely in patients who have acute cholecystitis with active inflammation or chronic cholecystitis with fibrosis of the gallbladder fossa or porta hepatis.

Patient factors – Severe obesity, previous upper abdominal surgery, and underlying liver disease (eg, cirrhosis) can predispose to complications.

Technical factors – The overall incidence of laparoscopic complications is also related to the experience of the surgeon [11,21-26]. Surgeons with more experience have lower complication rates [26]. Early experience with more advanced minimally invasive techniques (eg, single-incision laparoscopic surgery) further suggests higher bile duct injury rates compared with conventional laparoscopic cholecystectomy [27].

BILIARY INJURY — A major cause of ductal injury is diathermy burns, which may initially go unnoticed and usually involve the right or common hepatic ducts. Biliary injury may be recognized at the time of laparoscopic surgery; if so, conversion to an open procedure and repair of the injury should be attempted only if the surgeon is comfortable with advanced biliary surgery. If the injury is not recognized until after conclusion of the surgery, patients may be referred to a specialist for further care. Repair of major biliary duct injuries should be approached by a multidisciplinary team consisting of a surgeon, diagnostic radiologist, interventional gastroenterologist, and interventional radiologist.

Strasberg-Bismuth classification — A classification of biliary injuries is outlined in the figure (figure 1) [9]. The clinical presentation of the various injuries varies from asymptomatic bile leak that resolves spontaneously to complete obstruction of the extrahepatic biliary tree, which will present within days. On the other hand, segmental biliary tree obstruction may not present for several years after the procedure.

Type A – Type A leakage arises from injury to the cystic duct remnant or the bile ducts of Luschka [28]. It is not related to injury of the main bile ducts and has no loss in continuity of the biliary tree.

Leakage from the cystic duct remnant can result from laceration of a small cystic duct, dislodgement of one of the clips or ligatures on the cystic duct, ductal necrosis as a result of cholecystitis, or a distal obstruction in the common duct by a stone with resultant blowout of the cystic duct remnant (image 1).

The bile ducts of Luschka include both small ducts that distinctly enter the gallbladder bed and small tributaries of minor intrahepatic radicals of the right hepatic ductal system (image 2). Although true ducts of Luschka cannot be avoided, injury to these tributaries is probably caused by dissection into the liver parenchyma. Regardless of origin, both can continue to leak after removal of the gallbladder. Although type A leaks may occur subclinically, patients who develop bile peritonitis from the leak will need treatment. (See 'Management' below.)

Type B and C – These are occlusion (type B) and transection (type C) injuries of aberrant right hepatic ducts. These are associated with cystic duct drainage into an aberrant right hepatic duct, an abnormality seen in as many as 2 percent of patients. In this setting, the right hepatic duct can be mistaken for the cystic duct at the point of insertion into either the main hepatic duct or common bile duct.

When the injury to the duct is an occlusion (type B), the patient may remain asymptomatic for years and then present with right upper quadrant pain, and fever due to recurrent cholangitis and segmental fibrosis and/or atrophy may result. In comparison, a biliary leak occurs when the duct is transected but not occluded (type C). Concomitant injuries to the right hepatic artery are frequently associated with this problem. (See 'Vascular injury' below.)

Type D – These are injuries with lateral damage to the common bile duct resulting in a biliary leak; they can usually be managed endoscopically but may progress to the more serious type E injury. (See "Endoscopic management of postcholecystectomy biliary complications".)

Type E – Type E injuries involve the main ducts and are classified according to the level of injury in the biliary tree (Bismuth classification) (figure 1). Affected patients typically present with jaundice weeks to years after cholecystectomy [29]. Surgical repair via a hepaticojejunostomy is almost always required.

E1 (Bismuth type I) – Transection >2 cm from the confluence

E2 (Bismuth type II) – Transection <2 cm from the confluence

E3 (Bismuth type III) – Transection in the hilum

E4 (Bismuth type IV) – Separation of major ducts in the hilum

E5 (Bismuth type V) – Type C injury plus injury in the hilum

Bile leaks (type A, C, D injury) — Biliary and cystic duct leaks represent type A, C, and D injuries (figure 1). (See 'Strasberg-Bismuth classification' above.)

Presentation — Major biliary leakage is usually seen 2 to 10 days postcholecystectomy. Affected patients typically present with fever, abdominal pain, and/or bilious ascites. Jaundice may also be present. Leukocytosis and abnormal liver function tests, particularly elevations in serum alkaline phosphatase and gamma-glutamyl transferase, are common. Bilirubin will be mildly elevated as the body reabsorbs third-spaced bile.

Imaging — Upon presentation, we initially perform transabdominal ultrasound (US) to define the extent of the bile leak. Bile leaks can present as contained, loculated collections in the gallbladder fossa (image 3) or around the liver or as frank, diffuse biliary peritonitis. Ultrasonography can also determine if the intrahepatic ducts are dilated (and at what specific level), suggesting common duct obstruction. If necessary, better definition can be obtained by computed tomography (CT) scan (image 4), which is very sensitive in detecting intraperitoneal or pelvic free fluid.

Large loculated collections may need to be percutaneously drained by a radiologist using CT or US guidance with a catheter left in place for ongoing drainage (image 5) [30,31]. Bilious fluid is highly suggestive of a bile leak.

After the demonstration of fluid in the peritoneal cavity, we obtain a hepatobiliary iminodiacetic acid (HIDA) scan to delineate leakage of radiotracer into the peritoneal cavity and confirm that the fluid is bile. Biliary scintigraphy cannot anatomically localize the site of injury but is diagnostic of an ongoing bile leak in virtually all patients [32]. Early films are useful for major leaks (image 6), but delayed films approximately three hours after injection of tracer should be obtained if the early scans are negative (image 7). If the HIDA scan confirms an active bile leak, determination of the site of the leak is usually made by endoscopic retrograde cholangiopancreatography (ERCP) (image 8).

HIDA scans are not necessary if it has been confirmed by percutaneous drainage that the patient has bilious intraperitoneal fluid. One can proceed to ERCP in this scenario without a HIDA scan as it adds little to the clinical identification of the site of the leak. Rarely, if the ERCP is unable to demonstrate the site of leakage, a HIDA scan may be necessary to identify a branch in discontinuity with the biliary tree that is the source of the leak (eg, type C injury).

Magnetic resonance cholangiopancreatography (MRCP) is an alternative way of assessing the bile ducts [10]. MRCP offers a noninvasive method of diagnosing a bile leak, identifying the source of the leak, and identifying stones present in the bile duct, although it does not allow direct intervention as is possible with ERCP. MRCP can be particularly useful for complete imaging of the biliary tree (image 9A-B) [33]. This is especially important in cases of hilar injury such as a right posterior segmental duct transection or obstruction, where identification via ERCP may not be as thorough. MRCP allow for precise identification of the injury site because the contrast agents are excreted in the bile [34,35]. This can be useful for distinguishing leaks from the gallbladder fossa dissection bed from those of cystic duct origin. The modality (ERCP versus MRCP) chosen for investigation depends on the suspected injury pattern as well as local expertise in or availability of techniques.

Management — Almost all type A and D injuries can be managed by insertion of a biliary stent across the ampulla at the time of the ERCP to decrease pressure in the proximal biliary system (image 10) [36-38]. As an alternative, a sphincterotomy can be performed to promote free flow of bile across the ampulla without stent insertion. We favor the former approach and perform sphincterotomy only if there is common bile duct obstruction secondary to choledocholithiasis. Stenting results in a rapid decrease in the drainage of bile through the percutaneous drains, which can often be removed in three to five days. (See "Endoscopic management of postcholecystectomy biliary complications".)

There are certain cases in which, despite these minimally invasive therapeutic maneuvers, the patient continues to have severe abdominal pain from bile peritonitis or evidence of progressive intra-abdominal sepsis. In such cases, operative exploration and washout (achieved by either open or laparoscopic means) is effective. In addition, continued bile leak following appropriately positioned biliary stent may be due to a ductal injury that is not in continuity with the main biliary tree, commonly the right hepatic duct system (ie, type C injury).

Subsequent management varies with the type of injury:

In type A injuries, the stent can be removed endoscopically at two weeks if the patient is asymptomatic, the liver function tests are normal, and there is no ongoing leak at the follow-up ERCP.

In type C and D injuries, a repeat HIDA scan is performed two to four weeks after stent insertion. If there is no leak, the stent can be removed endoscopically at repeat ERCP. If there is a minor leak at the time of stent removal, we usually either perform a sphincterotomy to facilitate bile flow into the duodenum or replace the stent for a further four weeks.

The success of endoscopic treatment of type D injuries is dependent on the degree of bile duct injury. Many type D injuries with lesser degrees of damage can be effectively managed in the short term by stenting. However, close clinical follow-up with repeated diagnostic ERCP or MRCP may be necessary as these patients are at risk for developing late type E injuries due to stricture development from either the progressive effects of diathermy injury or the natural healing process. Injuries encompassing a larger circumference usually cannot be treated successfully by stenting alone and will require operative intervention.

Total endoscopic management of type C injuries is less successful because by definition, a segment of biliary drainage from the liver is "disconnected" from its natural flow into the distal biliary tree. Such patients may initially require percutaneous transhepatic cholangiography (PTC) catheter drainage to determine the anatomy of the injury before ultimately undergoing operative repair.

Occlusive injury to the right hepatic duct (type B injury) — Occlusive injury to the right hepatic duct is usually an occult injury that results in a segmental cholestasis in the liver and, after many years, atrophy of the right lobe. Some of these patients develop cholangitis secondary to infection or even intrahepatic stone disease. Symptomatic patients present with pain and features of cholangitis. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management".)

The diagnosis is usually made by ERCP, which shows an absent segmental hepatic duct on the right side, or by MRCP, which shows an obstructed segment lacking continuity with the distal biliary tree. CT scan may show focal atrophy or cystic dilation, and a percutaneous cholangiogram may be necessary to show ductal obstruction and overall biliary anatomy.

Treatment is surgical, involving preferably a hepaticojejunostomy; segmental resection of the affected lobes may also be necessary if atrophy is significant.

Injuries to common bile or common hepatic ducts (type E injury) — Injuries to common bile or common hepatic ducts are the most serious and are similar to the injury most commonly seen with open cholecystectomy.

Presentation — The clinical manifestations of these injuries are highly variable, depending upon whether the main duct is completely transected or clipped with no leakage of bile. If a bile leak occurs, it may be recognized at the time of the laparoscopic cholecystectomy. However, most injuries are not recognized at the time of initial surgery. Early presentation of bile duct injury after laparoscopic cholecystectomy is generally nonspecific, with patient complaints of vague abdominal pain, persistent nausea and vomiting, and low-grade fever [39]. Other patients can present with jaundice weeks to years after surgery.

Imaging — With complete occlusion or transection of the common bile duct, ultrasonography shows dilated intrahepatic ducts. ERCP is usually performed, revealing complete obstruction in the extrahepatic biliary tree with no filling of intrahepatic ducts.

Management — If a biliary injury is recognized intraoperatively and is limited in scope, a surgical repair can be attempted by T-tube drainage of the common bile duct at the site of the injury. Primary repair of the bile duct should be avoided because of its high propensity for breakdown or stricture formation in the setting of a normal-caliber common bile duct. In cases of more significant damage to the duct, a hepaticojejunostomy is preferable. (See "Repair of common bile duct injuries".)

If the surgeon is not experienced with advanced biliary surgery, they should obtain intraoperative consultation with a specialist who is skilled in this problem [40,41]. External drainage of the gallbladder fossa should be achieved prior to referral to a specialist.

If a complete common bile duct obstruction is diagnosed after the laparoscopic cholecystectomy, a combined percutaneous transhepatic cholangiography and ERCP technique can be used to treat the occlusion with good long-term results. However, most strictures that are of high grade and over 1 cm in length are not good candidates for endoscopic therapy. Thus, once the liver has decompressed, a hepaticojejunostomy is usually the treatment of choice, using the indwelling stents as a guide to identification of the ducts [42]. (See "Percutaneous transhepatic cholangiography in adults" and "Endoscopic management of postcholecystectomy biliary complications" and "Repair of common bile duct injuries".)

VASCULAR INJURY — Biliary injuries from laparoscopic cholecystectomy are accompanied by concomitant vascular injuries in 12 to 61 percent of cases [43]. A vascular injury can extend the biliary injury to a higher level than anatomically perceived due to ischemia; a combined vasculobiliary injury can also lead to liver infarction in about 10 percent of patients [44].

Vascular injuries are not included in the Strasberg-Bismuth biliary injury system mentioned above [45]. Due to its proximity to the bile duct, the right hepatic artery is most often injured.

A right hepatic artery injury is not always recognized clinically, because of collateral flow. If recognized intraoperatively, repair of the artery is rarely possible, and the overall benefit is unclear [46]. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the right hepatic artery for three months to avoid ischemic stricture of the bilioenteric anastomosis [13,44].

Injuries involving the portal vein or common or proper hepatic arteries are less common but have more serious effects, including rapid infarction of the liver. Such patients should be referred to a hepatobiliary center as soon as possible [13].

Patients who suffer hepatic infarction as a consequence of vasculobiliary injury may require hepatic resection or liver transplantation. Liver transplantation is indicated either for acute liver failure due to ischemic liver with massive necrosis caused by hepatic artery or portal vein occlusion [43] or for cirrhosis as a late complication of the injury [47,48].

BLEEDING COMPLICATIONS — The incidence of uncontrollable bleeding from laparoscopic cholecystectomy is 0.1 to 1.9 percent and can occur from three sources – the liver, blood vessels, or port insertion sites.

The middle hepatic vein and its radicals are in close proximity to the gallbladder fossa in up to 10 to 15 percent of patients [49]. Significant bleeding from the liver bed can occur in such patients during the final aspects of the removal of the gallbladder from the hepatic fossa. If attempts at laparoscopic hemostatic control fail, the case needs to be converted to open for suture ligation of the bleeder.

Arterial control issues involving the cystic artery can be identified immediately and controlled with clips (only if anatomical landmarks can be safely ensured, or else there is a high association with right hepatic arterial injury). They may also first be evident postoperatively as an acute hemodynamic decline requiring resuscitation, transfusions, and often reoperation. The culprit is usually a dislodged clip in this scenario.

Finally, incision or trocar sites can bleed. Patients usually present subacutely during the first postoperative days. We advocate direct visualization of trocar removal at the end of the laparoscopy so that such a problem can be addressed with laparoscopically placed sutures if necessary. When patients present with delayed bleeding, the diagnosis of hematoma can be made with visualization of a heterogeneous fluid collection on ultrasonography (US). If US examination is not diagnostic, abdominal wall and intraperitoneal hematomas can be visualized on CT as areas of higher attenuation [10]. If the patient is hemodynamically unstable, direct evaluation by re-laparoscopy is advocated.

BOWEL INJURY — Inadvertent bowel injury has been described in approximately one to four cases in 1000 laparoscopic procedures in various reports [19,50,51]. Management of this complication is dictated by the clinical scenario.

If the injury is noted at the time of surgery, then conversion to an open procedure for repair is indicated if it cannot be repaired laparoscopically.

Patients may present with trocar site pain, abdominal distention, diarrhea, leukopenia, and cardiovascular collapse from sepsis, typically within 96 hours of the procedure [51]. If the patient is septic or has free air, then an emergency laparotomy is indicated.

In cases where the presentation is more indolent and controlled, standard enterocutaneous fistula management with nutritional support and adequate drainage and wound care is appropriate. (See "Enterocutaneous and enteroatmospheric fistulas".)

POSTCHOLECYSTECTOMY SYNDROME — Postcholecystectomy syndrome (PCS) is a complex of heterogeneous symptoms including persistent abdominal pain and dyspepsia that recur and persist after cholecystectomy. This is presented in detail elsewhere. (See "Laparoscopic cholecystectomy", section on 'Postcholecystectomy syndrome'.)

QUALITY OF LIFE AFTER BILE DUCT INJURY — The occurrence of a bile duct injury incurs a significant burden on patients and surgeons alike.

Evidence, including data from a meta-analysis, indicates that mental quality of life (QOL) domains are more often negatively influenced than are physical domains [52]. In a registry-based study of over 710,000 cholecystectomies performed between 2005 and 2014, bile leaks occurred in 3551 patients (0.50 percent) and were managed almost exclusively endoscopically [53]. Bile duct injuries occurred in 1584 patients (0.22 percent) with 84 percent managed surgically. Patients with a bile leak were more likely to die at one year (2.4 versus 1.4 percent; odds ratio 1.85; p<0.001). Similarly, patients with a bile duct injury had an increased one-year mortality (7.2 versus 1.3 percent; odds ratio 2.04; p<0.0001).

For surgeons, bile duct injury remains one of the most litigious events in general surgery [54,55].

INJURY PREVENTION — The "critical view of safety" is a surgical technique designed to help the surgeon avoid bile duct injury [6]. Using this approach, Calot's triangle is dissected free of all tissue except for the cystic duct and artery, and the base of the liver bed is exposed (figure 2). When this view is achieved, the two structures emanating from the gallbladder (cystic duct and cystic artery) and the interface with the liver at the base of the gallbladder fossa (cystic plate) should be definitively identified [9]. This is optimally achieved by obtaining a "doublet" view of both the anterior and posterior aspects of Calot's triangle [56,57]. Adequate documentation of safety maneuvers is strongly encouraged [58,59]. (See "Laparoscopic cholecystectomy", section on 'Critical view of safety'.)

Difficulty with identification of the critical view should lead the surgeon to consider performing cholangiography, performing a subtotal cholecystectomy, or converting the laparoscopic cholecystectomy into an open procedure [60,61]. The critical view of safety technique was employed in a study of 1046 consecutive patients who underwent laparoscopic cholecystectomy from 2002 to 2007, with no bile duct injury [62]. Recognition of biliary injury may be more likely if routine intraoperative cholangiography is performed [40,41]. However, the value of this approach is controversial [63]. Some studies found no overall benefit of routine intraoperative cholangiography, which, it was suggested, should be limited to patients suspected of having a common bile duct stone (which is managed by endoscopic retrograde cholangiopancreatography [ERCP]) or if biliary anatomy is unclear [63]. This is discussed in detail elsewhere. (See "Surgical common bile duct exploration", section on 'Intraoperative cholangiography'.)

These and other safety measures that should be employed when performing a difficult cholecystectomy are the focus of another UpToDate topic. (See "Managing the difficult gallbladder".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallbladder surgery" and "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

Incidence – Serious complications of laparoscopic cholecystectomy include bile duct injury (0.1 to 0.3 percent), bile leaks (0.3 to 0.5 percent), bleeding (0.1 to 1.9 percent), and bowel injury (0.1 to 0.4 percent). (See 'Incidence' above.)

Risk factors – Complications result in part from anatomic variants, inherent patient disease and comorbidities, and the technical constraints of the minimally invasive approach. (See 'Risk factors' above.)

Bile leak – Biliary leakage should be suspected when patients present after cholecystectomy with fever, abdominal pain, and/or bilious ascites. Large loculated collections should be percutaneously drained with radiologic guidance and a catheter left in place for continuing drainage. Endoscopic retrograde cholangiopancreatography (ERCP) may define the leak and allow stent placement. (See 'Bile leaks (type A, C, D injury)' above.)

Right hepatic duct occlusion – Occlusive injury to the right hepatic duct results in a segmental cholestasis and ultimately atrophy of the right lobe after many years. It is usually diagnosed by ERCP and corrected with a hepaticojejunostomy; segmental resection of the affected lobes may also be necessary if atrophy is significant. (See 'Occlusive injury to the right hepatic duct (type B injury)' above.)

Common bile or common hepatic duct injury – Injuries to common bile or common hepatic ducts are the most serious complications and can have variable clinical presentations. (See 'Injuries to common bile or common hepatic ducts (type E injury)' above.)

Limited injuries to common bile or common hepatic ducts that are recognized at the time of surgery can be repaired by T-tube drainage of the common bile duct. Primary repair of the bile duct should be avoided because of the high rates of breakdown or stricture formation. In cases of more significant damage to the duct, a hepaticojejunostomy will be required.

The delayed presentation of common bile or common hepatic duct injuries includes complaints of vague abdominal pain, persistent nausea and vomiting, low-grade fever, and jaundice (if patients present late). Initial treatment requires decompression of the liver with percutaneous stents to reduce the risk of cholangitis and define the injury. Although some patients can be treated with dilation and stent insertion by ERCP, most will require a hepaticojejunostomy.

Vascular injury – Biliary injuries from laparoscopic cholecystectomy are accompanied by concomitant vascular injuries in 12 to 61 percent of cases, most commonly of the right hepatic artery. Right hepatic artery repair may not be possible or beneficial; however, consideration should be given to delaying repair of a biliary injury in patients with occlusion of the right hepatic artery for three months to avoid ischemic stricture of the bilioenteric anastomosis. Common or proper hepatic artery or portal vein injuries are more serious and require emergency transfer to a hepatobiliary center. Liver infarction occurs with 10 percent of vasculobiliary injury and may require resection or transplantation. (See 'Vascular injury' above.)

Bleeding – Bleeding can occur from the liver, blood vessels, or port insertion sites. Management of this complication is dictated by the clinical scenario. (See 'Bleeding complications' above.)

Bowel injury – Inadvertent bowel injury can occur with any laparoscopic procedure. Management of this complication is dictated by the clinical scenario. (See 'Bowel injury' above.)

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Topic 3681 Version 25.0

References

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