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Surgery and Health

Gallbladder, removal and risks

Laparoscopy Cholecystectomy And Common Bile Duct Injury

By Dr. W. Gifford Jones

January 16, 1993

What is the best way to have your gallbladder removed? Two years ago I peered into my crystal ball and made a prediction about "laparoscopy cholecystectomy", the new method of removing gallbladders. I prophesied that some patients would face dire complications after this procedure. How right was my crystal ball?

Á First, my first assumption was wrong? I believed that laparoscopy cholecystectomy would be used gradually as an alternate procedure in many cases. I failed to predict that within four short years 80 per cent of gallbladders in the U.S. would be removed by this technique.

Á But one prediction was right on. I was convinced that there would be a significant number of injuries to the common bile duct (CBD), the small tube that carries bile from the liver to the small intestine. Injury to the CBD is a major complication that may cause jaundice and liver damage.

Á Dr. Gregory Bulkey, Professor of Surgery at Johns Hopkins University, reports that " There does appear to be a substantial increase of bile duct injury". Removing the gallbladder by a normal surgical incision results in damage to the bile duct once in every 1,000 operations. Bulkey reports it's five times greater with laparoscopy.

Á Dr. Bulkey makes another equally pertinent comment. He says the risk of injury to the CBD may be even greater because surgeons may not be reporting all of their cases with complications.

Á There's evidence this is not pure speculation. For example, it's interesting that many university centers are reporting low complication rates for laparoscopy cholecystectomy. But these same centers are also seeing increased numbers of patients being referred to them to correct common bile duct injury! That tells the story.

Á I have no reason to doubt that there's been considerable Under-reporting of CBD complications. My contacts at university hospitals in the U.S. inform me that there's never been a time when more common bile duct injuries have been seen.

One did not need the Wisdom of Solomon to have foreseen this problem. Good sense dictates that, even in the best of hands, removing a gallbladder by looking into the abdomen with optical instruments is a far cry from removing one through a large incision.

The new technique involves making four puncture holes in the abdomen. The laparoscope, like a periscope in a submarine, is inserted through the largest hole. This allows the surgeon to view the gallbladder, which can also be seen on a T.V. screen. Operating instruments are then inserted through the other holes and the organ gradually excised from its attachment to the liver.

  What happened is that many surgeons, for competitive reasons, rushed to training centers to learn this technique on pigs. Then hurried home to operate on humans. But it takes time and much skill to master the three dimensional approach of laparoscopy.

Á That's why medical consumers should be sceptical of the recent statement released by the U.S. National Institute of Health. This organization has endorsed laparoscopy cholecystectomy as a safe alternative for gallbladder removal.

Á So what should you do if your doctor recommends laparoscopy cholecystectomy? Remember there are some important advantages to this technique. You'll have far less pain and will likely be sent home the following day. And there's practically no chance of an incisional hernia developing. If everything goes well it's undoubtedly the best way to remove a diseased gallbladder.

Á But it's vital that you clarify certain points with the surgeon. Don't be shy about asking where the surgeon received his training. Was it during his hospital surgical residency when professors were helping him operate on human patients? Or did he take a course in a non-university setting where he operated on pigs?

Á The most important question, "How many has he or she done?" The learning curve of competency in laparoscopy cholecystectomy is long and slow. So if the surgeon has not done at least 50 you should not agree to the procedure unless he plans to have a surgeon assist him who is experienced in the technique.

Á During a recent visit to a major University hospital in the U.S. I questioned a colleague about the technical dexterity of it's surgeons performing this procedure. He advised me with some impatience that they were all capable, and it made no difference to whom he referred his patients.

If God is in Heaven, the birds singing, and the sun shining I still question this remark. No two technicians have the same skills whether when fixing a car, a leaking pipe, or doing surgery. Never let anyone convince you otherwise. Moreover the greater the technical skill required for an operation the more important this point becomes. It's preferable if your surgeon communicates easily and has a good disposition. But if he or she has the personality of Dracula accept it. Never forget his hands, not his bedside manner, will be doing the surgery.


W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of Harvard. Dr. Walker's website is: Docgiff.com

My book, �90 + How I Got There� can be obtained by sending $19.95 to:

Giff Holdings, 525 Balliol St, Unit # 6,Toronto, Ontario, M4S 1E1

Pre-2008 articles by Gifford Jones
Canada Free Press, CFP Editor Judi McLeod