IATROGENIC INJURIES OF SUBVESICAL BILE DUCT - CASE REPORT AND LITERATURE REVIEW

With the rise of laparoscopic cholecystectomy as the gold standard for treating gallbladder calculi andpolyps, subvesical bile ducts are gaining increased clinical importance. With the introduction of electrocautery insurgery, a large part of these tubular structures, although with interrupted continuity, do not show extravasation ofbile content postoperatively. Decreased bile production during general anesthesia and increased intraperitonealpressure also make diagnosis of injuries difficult. Surgeons who frequently operate in the right upper quadrant haveto understand the anatomy of the biliary tree and its tendency for structural variation. The work of laparoscopicsurgeons should be conceptualized around three main goals: to enable safe identification of key anatomicalstructures, usually by providing a critical point of safety (Critical View of Safety), to make a decision at the rightmoment not to proceed with laparoscopic surgery when working conditions become too dangerous and there is nopossibility of identification of structures and to end the laparoscopic surgery with subtotal cholecystectomy whenidentification of structures is impossible. Controversy among authors on the naming of the various subvesicalstructures causes confusion in their identification and description. In order to overcome these challenges, there was aneed to establish classification systems for post-cholecystectomy lesions of the biliary tract. But due to theindividual shortcomings of all these systems, in June 2011, during the 19th meeting of the European Association forEndoscopic Surgery in Turin, Italy, a conference was held to reach a consensus to establish a uniform classificationof iatrogenic bile duct injuries that will have two primary goals: first, to take into account changes in the type ofinjuries with the introduction of laparoscopic cholecystectomy, and second, to combine all existing classificationsystems and integrate them into one, universally accepted classification system. As part of the new inclusiveclassification system for iatrogenic injuries of the biliary ducts, the following systems are considered: Bismuth,Strasberg et al., McMahon et al., AMA, Neuhaus et al., Csendes et al., Steward et al., Hanover, Lau and Lai ,Siewert et al., Cannon et al., Kapoor., Sandha et al.. In the new system a total of fifteen classifications areincorporated using semantic connotations and grouped into three categories that will allow easy memorization bysurgeons. A (anatomy) for anatomy, To (time of) for time/moment of observation and M (mechanism) for themechanism of occurrence of the injury. By enabling a more precise classification of each of the injuries, the surgicalcommunity will have the opportunity to develop recommendations for prevention, treatment and prognosis for theiroutcome.