Iatrogenic injury to the bile duct. Who, how, where?

We reviewed 81 patients with bile duct injuries that occurred at cholecystectomy and/or common bile duct exploration. Thirty-two of the strictures were recurrent. The median follow-up was 9 years. High injuries were inflicted during the performance of cholecystectomy while low injuries were related to common bile duct exploration. Mitigating circumstances appear to be as follows: (1) inadequate access, exposure, and assistance; (2) absence of operative cholangiogram; (3) patient's obesity; and (4) early dissection of Calot's triangle. Noncontributory factors include the following: (1) level of training of surgeon, and (2) type of institution where the operation was performed. Following repair, 15 patients eventually died and 8 suffered intermittent cholangitis and/or cirrhosis. Mortality and morbidity were related to the following: (1) level of stricture; (2) number of previous attempts at repair; and (3) adequacy of reconstruction. Mucosa-to-mucosa anastomosis without tension is essential for optimal results.