Commentary on “Cystic Duct Leaks After Laparoendoscopic Single-Site Cholecystectomy”: A Word of Caution

Laparoendoscopic single-site surgery (LESS) has gained interest in recent years as a virtually “scarless” alternative to conventional multiport laparoscopic approaches. While LESS procedures can often be performed with conventional instrumentation, the loss of triangulation in instrument placement and the in-line view of the anatomy present visual and technical challenges to the surgeon. In cholecystectomy, where the potential for biliary injury poses the greatest risk to the patient, these challenges raise concerns about whether the LESS approach will result in more biliary or other complications. Despite these challenges, it has been shown that the critical view of safety can be routinely identified with this approach, ¹ and of the many small series reported in the literature, there have to date been no red flags of a higher incidence of biliary injury.

In this background, Sinha and Chandra ² now report five patients who developed biliary peritonitis after LESS cholecystectomy. The authors have by far the largest series of LESS cholecystectomy procedures to date, with 756 reported cases. The incidence of biliary peritonitis in this series was 0.66%. Four of these were cystic duct stump leaks, and one was a right hepatic duct injury that was repaired at the time of laparoscopic cholecystectomy.

The development of a cystic duct stump leak after laparoscopic cholecystectomy, regardless of the approach, is not a benign event. Eisenstein et al. ³ identified 12 cystic duct stump leaks in a series of 5501 laparoscopic cholecystectomies (for an incidence of 0.21%). The vast majority of these events were managed by endoscopic retrograde cholangiopancreatography (ERCP), but 1 patient died from this complication. In the present series, the authors do not indicate what their rate of biliary peritonitis was with standard laparoscopic cholecystectomy. Four of the 5 patients with biliary leaks after LESS cholecystectomy had acute cholecystitis, and the cystic duct was “edematous” in each of those 4 patients. Moreover, 2 patients had common bile duct stones seen on postoperative ERCP. It is notable that none of the patients in this entire series had an intraoperative cholangiogram. These complications were not inconsequential. Two patients required percutaneous drainage in addition to ERCP and stenting, and 1 patient developed an adhesive intestinal obstruction that required a laparotomy.

It is unclear from this study in the absence of data indicating the authors' biliary leak rate with multiport laparoscopic cholecystectomy as to whether the biliary complications in this series were primarily from the LESS approach or for other technical reasons. In the setting of an edematous or cystic duct, a better strategy to secure the duct may be to use a pretied loop suture rather than to simply rely on clips. Moreover, the 0% rate of cholangiograms in this series is of concern. Previously, it has been shown that cholangiography can be performed with a high degree of success in the setting of a single-incision laparoscopic approach to cholecystectomy. ¹ Had the 2 patients with common bile duct stones been identified at operation, the perioperative management algorithm may have been different, and the biliary leaks potentially avoided.

Regardless of the approach, attention to details of securing the cystic duct stump is paramount in preventing these complications and should not be compromised in order to carry out the procedure with a single-port technique. The authors are to be commended for recording their results and for pointing out the risks and underappreciated nature of this complication.