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 Table of Contents     
PERSONAL VIEWPOINT
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 292-294
 

Bile duct injury during cholecystectomy: Culpable or unintentional ‘Choledochocide'


Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission12-Feb-2020
Date of Acceptance13-Feb-2020
Date of Web Publication06-Jun-2020

Correspondence Address:
Prof. Vinay Kumar Kapoor
Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_35_20

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How to cite this article:
Kapoor VK. Bile duct injury during cholecystectomy: Culpable or unintentional ‘Choledochocide'. J Min Access Surg 2020;16:292-4

How to cite this URL:
Kapoor VK. Bile duct injury during cholecystectomy: Culpable or unintentional ‘Choledochocide'. J Min Access Surg [serial online] 2020 [cited 2020 Jul 4];16:292-4. Available from: http://www.journalofmas.com/text.asp?2020/16/3/292/285929




Gallstones (GS) are common all over the world, including India, more so in North India. Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic GS. Bile duct injury (BDI) is a serious complication of cholecystectomy, more so of LC. There is a learning curve for LC but BDI can (and does) occur even in the hands of experienced surgeons. BDI results in major morbidity and can even cause death.[1] BDI is a common cause of litigation against the surgeon. Majority of the BDIs are considered as negligence on the part of the surgeon and more than half of the cases are accepted, i.e., decided in favour of the patient and against the surgeon, and large amounts of compensation are awarded. The litigation is usually prolonged and causes distress as well as disrepute to the surgeon.[2] Every surgeon who performs LC should be prepared to face a litigation for BDI at least once in his/her career.

Homicide (Latin: Homi = man, cide = kill).

Homicide is killing of a person. Homicide is classified into various degrees:

  1. Section 300 of the Indian Penal Code (IPC) defines intentional (with a malice intention), premeditated (planned) and unlawful (without any justification) homicide as a murder
  2. Section 299 of the IPC defines unlawful killing which is done in the heat of the moment caused by sudden provocation, but when there was no premeditation nor an intent to kill as a culpable homicide, not classified as (i.e., not amounting to) murder
  3. When there is no intent to kill nor the knowledge that death will occur but a person gets killed due to carelessness or reckless behaviour, e.g., driving under the influence of alcohol; it is classified as unintentional homicide; it is the least serious degree of homicide
  4. Some homicides which are done without criminal guilt, e.g., that done in self-defence, are called justifiable (excusable) homicide
  5. Medical termination of pregnancy, separation of two unequal conjoint twins where one is bound to die and euthanasia (wherever legal) are examples of legal homicides
  6. Judicial hanging (capital punishment) and killing of an enemy in a war are lawful killings and are classified as state-sanctioned homicides.


Accordingly, the punishments are also different for different degrees of homicides:

  1. Punishment for a murder is death or imprisonment for life (Section 302 of the IPC)
  2. Punishment for a culpable homicide, not classified as (i.e., not amounting to) murder, is imprisonment for life or for 10 years (Section 304 of the IPC)
  3. Punishment for unintentional homicide caused by a rash or negligent act is imprisonment for 2 years (Section 304A of the IPC)
  4. One may escape any punishment for a justifiable homicide done in self-defence
  5. There is obviously no punishment for legal or state-sanctioned homicides.


‘Choledochocide’ (Choldochus = common bile duct (CBD), cide = excise, cut, divide or injure).

I would like to name excision, cutting, division or causing an injury to the CBD as ‘choledochocide'.

  1. Excision of an abnormal (diseased) CBD, e.g., in cholangiocarcinoma, choledochal cyst and gallbladder cancer infiltrating the CBD is lawful ‘choledochocide’ as it is required for the treatment of the disease
  2. Excision of a normal (non-diseased) CBD, e.g., in pancreatoduodenectomy is an intentional but justifiable ‘choledochocide’ as it is an essential part of the planned surgical procedure
  3. I am of a firm belief that no surgeon will ever perform an intentional (with a malice intention) and unlawful unjustifiable ‘choledochocide’ for a normal CBD during any operation but an unjustifiable, though unintentional, ‘choledochocide’ i.e., a BDI may (does) occur during a cholecystectomy.


Medicolegal opinion

With an experience of the management of more than 1000 post-cholecystectomy BDIs referred to us at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, over the last three decades, it is very likely that I may be called by the consumer forum or a court of law to give an expert opinion in a medico-legal case filed by a patient against the surgeon for a BDI during cholecystectomy. The BDI itself indicates that a ‘choledochocide’ has occurred, but my job as an expert will be to decide whether the BDI is a complication (adverse event) inherent to the surgical procedure, i.e., LC, itself or a mistake (negligence) on the part of the surgeon. In order to decide this, I will consider the following aspects:

  1. The surgeon had received proper and adequate training in LC either as a resident or later as a full-time observer for an adequate period of time in a department regularly performing LC (and not just attendance at a weekend course or workshop)
  2. The surgeon maintains records of all LC patients, namely preoperative workup, details of the operative findings and the operative procedure, complications, discharge and follow-up. It will be a point in favour of the doctor if he/she video records all LCs and preserves the recording till at least the first follow-up of the patient. If video recording is not possible/available, at least few pictures of the operative findings, especially of the Calot's triangle, are available. The incidence rate of BDI in the surgeon's hands (as evident from these records) as compared with the globally accepted incidence, i.e., 0.5% (1 in 200) of BDI in LC
  3. The surgeon performed complete preoperative workup including at least liver function tests (LFT) and a recent ultrasonography (US) in the index case. If there was any suspicion of biliary obstruction on LFT or US, preoperative magnetic resonance cholangiography/endoscopic retrograde cholangiography (ERC) was performed to rule out CBD stone (s)
  4. Proper complete detailed informed written consent was obtained from the patient. The consent form mentioned some of the common and all the major complications of LC, namely shoulder pain, wound infection, respiratory complications and BDI; chances of conversion, possibility of a partial cholecystectomy and risk of retained CBD stone (s) were mentioned in the consent form. A surgeon working individually in a small hospital may have a fear that mentioning all these complications and risks may drive the patient away from him/her to another surgeon who paints a false ‘rosy’ picture (no conversion, no complications and no risks) of LC but then one has to decide and choose between more patients on one side versus a possible litigation on the other
  5. If equipment and expertise were available, the surgeon performed intraoperative/peroperative cholangiography, intraoperative US, indocyanine green cholangiography to delineate the biliary ductal anatomy. It is acceptable if these are not available (as is likely to be the case in most hospitals), but the surgeon called another colleague available in the vicinity to obtain an independent unbiased opinion about the biliary ductal anatomy to avoid the visual perception error of mistaking the CBD for the cystic duct (and the right hepatic artery for the cystic artery)– in vicinity colleaguography[3]
  6. If the BDI was detected intraoperatively, the surgeon did not make any attempt to repair it; instead, he/she placed drains to convert the acute BDI into a controlled external biliary fistula. Repair by the injuring surgeon (unless he/she is a biliary surgeon)/in the injuring hospital (unless it is a biliary centre) is a risk factor for litigation. In case of a litigation, the case is more likely to be accepted, i.e., decided in favour of the patient and against the surgeon in case the repair is attempted/done by the injuring surgeon/in the injuring hospital
  7. If and when a BDI or bile leak was suspected in the post-operative period, appropriate investigations, e.g., total leucocyte count, differential leucocyte count, LFT, US/computed tomography (CT)/magnetic resonance imaging (MRI) isotope hepatobiliary scintigraphy/scintigraphy were done in time; delay in imaging and diagnosis is a risk factor for litigation
  8. Appropriate measures, e.g., percutanoeus catheter drainage, relaparoscopy and relaparotomy were taken if bile leak and collection were found on investigations, e.g., US/CT/MRI. ERC and stenting (or endoscopic nasobiliary drainage tube placement) was asked for/done in time to stop/control the ongoing bile leak. If ERC reveals a cystic duct blow out due to a CBD stone which was not detected/suspected on preoperative investigations, the surgeon is not at fault
  9. The status of the patient at the time of discharge, namely general condition, vital signs and abdomen, is documented in the records. If a patient who is not well, has unstable vitals, namely fever, tachycardia; tachypnoea and has unsettled abdomen is discharged; I may consider it as negligence on the part of the surgeon. Clear verbal and written instructions were given to the patient to return to the hospital/surgeon in case of any problem, e.g., pain abdomen, fever, abdominal distension, nausea and vomiting, and jaundice.
  10. Patient was readmitted if he/she came back with symptoms/signs suggestive or even suspicious of BDI/bile leak or any other LC-related complications
  11. Patient and the relatives were informed about the complication, i.e., BDI and its planned management; and this communication is documented in the records. Proper honest communication with the patient/relatives is very likely to avoid a future litigation
  12. In case a BDI occurred and if facilities and expertise for interventional radiology and therapeutic endoscopy were not available in the injuring hospital (as is likely to be the situation in most cases), the patient, after initial resuscitation, was referred to an appropriate health-care facility (a biliary centre) with a proper detailed referral note describing the operative findings and the operative procedure, postoperative course, investigations done and their reports, management done and the status of the patient at the time of referral; late transfer to a higher centre is a risk factor for litigation. It will be a point in favour of the surgeon if he/she called the referral hospital/doctor (surgeon or gastroenterologist/endoscopist) and arranged for prompt admission of the patient in the referral hospital
  13. The surgeon is aware of and has read the recently published Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) Consensus Statement for Safe Cholecystectomy—Prevention and Management of BDI.[4],[5]


If most or many of the above conditions are met/present, I will probably rule an unintentional ‘choledochocide’ not amounting to negligence (i.e., not guilty) but if none or just a few of the above conditions are met/present, I will, unfortunately, have no option but to hold the surgeon guilty of culpable ‘choledochocide’ amounting to negligence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kapoor VK. Bile duct injury during cholecystectomy. Rozhl Chir 2015;94:312-5.  Back to cited text no. 1
    
2.
Kapoor VK. Medico-legal aspects of bile duct injury. J Minim Access Surg 2016;12:1-3.  Back to cited text no. 2
    
3.
Kapoor VK. ‘Colleaguography’ in place of cholangiography, to prevent bile duct injury during laparoscopic cholecystectomy. J Minim Access Surg 2019;15:273-4.  Back to cited text no. 3
    
4.
Bansal VK, Misra MC, Agarwal AK, Agrawal JB, Agarwal PN, Kapoor VK. SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A. Indian J Surg 2019. https://doi.org/10.1007/s12262-019-01993-2.  Back to cited text no. 4
    
5.
Bansal VK, Misra MC, Agarwal AK, Agrawal JB, Agarwal PN, Kapoor VK. SELSI Consensus Statement for Safe Cholecystectomy—Prevention and Management of Bile Duct Injury—Part B. Indian J Surg 2019. https://doi.org/10.1007/s12262-019-01994-1.  Back to cited text no. 5
    




 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04