Introduction: Laparoscopic cholecystectomy has become a standard procedure for gallbladder removal. With the recent spread of this procedure, the incidence of surgical complications has been increasing. This study was conducted to investigate the complications encountered during cholecystectomy at our department in order to establish preventive measures for such outcomes.
Materials and Methods: The subjects consisted of 126 patients treated with open cholecystectomy and 455 patients treated with laparoscopic cholecystectomy during the same period.
Bile duct injury was the most serious complication. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography were performed in all patients. We evaluated the usefulness of these examinations for the prevention of surgical complications. The relationship between the degree of the surgeon's experience and incidence of complications was also studied. The length of residual cystic duct was examined by magnetic resonance cholangiopancreatography (MRCP).
Results: Surgical complications were encountered in 2 patients undergoing open cholecystectomy and 12 patients undergoing laparoscopic cholecystectomy. Bile duct injury occurred in 2cases of open cholecystectomy and 7 cases of laparoscopic cholecystectomy. Injuries were located mostly in the cystic duct.
Biliary reconstruction was not required.Bile duct injury has not been encountered in the recent 3 years at our department probably because the skills of the surgeons have risen due to an increase in the number of treated cases. The length of residual cystic duct in laparoscopic cholecystectomy is longer than in open cholecystectomy
Conclusions: Serious complications during laparoscopic cholecystectomy can be avoided by performing accurate examination of the biliary system before and during surgery. We had no experience of complication at residual cystic duct, but we have to follow up more cases in the future.

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The aim of this study was to clarify the effect of obstructive jaundice on hepatic microcirculation and Kupffer cell activities. Common bile duct ligation was performed on C 57 BL/6 mice to induce obstructive jaundice. One and 2 weeks after the operation, leukocyte rolling and sticking, and hepatic sinusoidal blood flow were evaluated using hepatic intravital microscopy. Phagocytic activities were also quantitated using fluorescent latex particles. Leukocyte rolling increased significantly 1 and 2 weeks after bile duct ligation upto 409.5% of control. Hepatic sinusoidal blood flow, evaluated as the number of sinusoids containing blood flow per microscopic field, decreased significantly associated with increased phagocytic activities after bile duct ligation. These data suggest that obstructive jaundice results in increased leukocyte adhesion and Kupffer cell activities, which may impair hepatic microcirculation, and make a host susceptible to postoperative complications, such as hepatic failure.

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The treatment of bilateral lobe (LR) -type intrahepatic stones was studied in 3 groups of 33patients: 6 patients with primary intrahepatic stones; 16 patients with intrahepatic stones derived from common bile duct stones; and 11 patients with intrahepatic stones formed after operation. It was expected that, in many patients with primary intrahepatic stones, hepatic resection could be applied as successful radical treatment, judging from characteristics in the biliary morphology. In addition, the use of more selective hepatic resection, such as segmental or subsegmental resection, was presumed to expand the application of this operation. In patients with intrahepatic stones derived from common bile duct stones, therapy for the choledocholithiasis could underline the treatment. In some patients with intrahepatic stones formed after operation, the pathological features were very complicated. Of these patients, those with type-IV congenital bile duct dilatation performed extrahepatic bile duct resection and reconstruction were sometime difficult to treat at present because radical therapy was not available. With the exception of these cases, however, treatments were well achieved even for LR-type intrahepatic stones by selecting an appropriately applicable therapy corresponding to the pathological features.

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A 45-year-old man had been suffered from recurrent cholangitis and biliary stones since 1985, when he underwent EST for choledocholithiasis. Percutaneous transhepatic cholangiogram revealed intrahepatic bile duct stricture of the left hepatic duct and hepatolithiasis in the dilated B₃duct. Because of his refusal of operation, he was treated with lithotomy under percutaneous transhepatic cholangioscopy followed by the placement of a Wallstent^TM. However, he had recurrence of choledocho-hepatolithiasis again in 1999. Finally, we performed left lateral segmentectomy of the liver. This case indicated the importance of careful examination of the biliary tract before EST to exclude biliary stricture. Moreover, benign intrahepatic bile duct stricture with previously endoscopic papillotomy should be treated by operation, not interventional procedures to avoid stent related trouble.

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Mirizzi syndrome is the advancing stage of chronic inflammation due to cholecystolithiasis and may be to condition about biliobiliary fistula or confluence stone thus not improving naturally. We report a case of Mirizzi syndrome showing the improving findings of the bile duct stenosis caused by decompression of forming the cholecysto-duodenal fistula. A 43-years-old male was admitted to our hospital because of epigastralgea and right hypochondralgea. Reason about disappearance was decompressive effect by the formation of cholecysto-duodenal fistula confirming at the operation. We report a case of Mirizzi syndrome, because of natural improves or combination with internal bile fistula is reported to be rare in the literatures.

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We present a case of non-icteric hilar bile duct carcinoma. The patient who was a 67-year-old man had a fever and diarrhea. He exhibited leucocytosis and liver dysfunction without icterus. Computed tomography showed an abscess in the right lobe of the liver. US-guided percutaneous abscess drainage was performed but it took us about 3 months to cure the abscess completely. After that endoscopic retrograde cholangiogram revealed a 2.5 cm filling defect in the hilar bile duct and dilatation of the bile duct of the left lobe. Bile cytology showed Class IV and laparotomy was performed. Resection of the gallbladder and extra-hepatic bile duct were done. The tumor was 2.5×1.6 cm in size. Pathological analysis revealed papillary tumor in the bile duct, which was characterized as papillary adenocarcinoma (Br (anterior) cl, ss, n (-), hm₀, em₁). It is necessary to remember bile duct carcinoma as a probable cause of liver abscess. So the recognition and rapid treatment of an abscess are of importance.

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A 65-year-old female who had a chief complaint of upper abdominal discomfort, was admitted to our hospital with a diagnosis of gallbladder tumor by an abdominal ultrasonography. Endoscopic ultrasonography revealed gallbladder tumor associated with invasion into subserosa layer. Abdominal CT showed contrast enhanced tumor. Abdominal angiography showed tumor staining. Cytologic examination using endoscopic naso-gallbladder drainage tube showed cancer cells. Under diagnosis as gallbladder carcinoma, extended cholecystectomy was performed.
Histological examination showed the gallbladder cancer consisted of both endocrine cell carcinoma and small well-differentiated adenocarcinoma. Immunohistochemical examinations including p 53, showed same staining pattern in the part of both endocrine cell carcinoma and adenocarcinoma. Moreover both part showed same pattern of p 53 mutation. Therefore, in this case, these results suggested that endocrine cell carcinoma and adenocarcinoma were monoclonal, and that endocrine cell carcinoma was originated from adenocarcioma.

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A case of bile duct injury at hepatic hilum in laparoscopic cholecystectomy required a right hepatic lobectomy is reported. A 37-year-old man underwent laparoscopic cholecystectomy for cholelithiasis. He developed evidence of a bile leak on the first day of the operation. Twenty-one day after surgery, a laparotomy and drainage was performed. But a bile leak continued.
About 4 weeks after second operation, he was refered to our hospital because of suffering from acute cholangitis. Percutaneous transhepatic cholangiogram disclosed a obstruction between anterior and posterior hepatic bile ducts and a stricture of hilar bile duct. A computed tomography revealed a right subphrenic biloma. As we considered anastomotic strictures due to biloma at hepatic hilum and hypertrophic stenosis in intrahepatic bile duct, we were not able to use a biliary reconstruction by the Roux-en Y method. Because of these reasons, a right hepatic lobectomy and reconstruction of the left hepatic duct was performed. There is no evidence of cholangitis for 16months following operation.
This case is taken into consideration about the indication of hepatectomy for bile duct strictures by laparoscopic cholecystectomy.

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A case with multiple stones in the intrahepatic bile duct 5 years after pancreatoduodenectomy is presented. A 67-year-old female was admitted to our hospital because of the symptoms compatible with cholangitis. The patient was diagnosed as stage IVa gallbladder carcinoma 5 years before and underwent pancreatoduodenectomy associated with the partial hepatectomy and was reconstructed with a so called “Imanaga I” procedure. No findings indicating the recurrence of carcinoma had been noted during the follow-up period except a sustained and modest increase in plasma CA 19-9 level. Magnetic resonance cholangiopancreatography revealed a dilatation of intrahepatic bile duct and multiple biliary stones. Percutaneous transhepatic biliary drainage was performed and the stones were then removed under cholangioscopy. The cholangioscopy revealed a stenotic choledochojejunostomy of which size was 3 mm in diameter. The dilatation procedure using a balloon catheter was repeatedly performed to facilitate bile flow. No cancer cells were detected either from biopsy specimen obtained from the anastomotic site or bile fluid. A 24-Fr Nelaton catheter was placed in the stenotic site as a stent for 6 months and was then removed. No findings indicating anastomotic stenosis has been noted for 30 months after the removal of the catheter.

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Torsion of the gallbladder is not so rare, but difficult to diagnose preoperatively. A 65 year-old female was admitted our hospital, because of right hypochondral pain. Abdominal ultrasonography (US) revealed low echoic mass in the neck and computed tomography (CT) showed a direct image of the spirally twisted neck of the gallbladder. She was diagnosed the torsion of the gallbladder and underwent cholecystectomy. In the operation, the gallbladder had twisted counter-clockwisely about 180 degrees, and the wall was thickened remarkably and necrotic. Preoperative imaging is important for the differential diagnosis. Among some typical signs for the gallbladder torsion, the most characteristic signs are floating gallbladder and direct image of the twisted neck. Although the direct image of the twisted neck has been reported in many literatures, these findings in CT and US are not same, but different by cases. Twisted angle, edema, and time from onset might affect those findings. However, image diagnosis is helpful to distinguish gallbladder torsion from acute cholecystitis. If this disease is taken into account, preoperative diagnosis is possible.

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We report the case of a 56-year-old man with intrapancreatic biliary diverticulum (type II by the Todani/Alonso-Lej classification) undergoing resection of intrapancreatic bile duct. The patient presented back pain, vomiting, and fever. Laboratory tests showed mild liver dysfunction. Endoscopic retrograde cholangiopancreatography demonstrated an 8 mm biliary diverticulum at 16mm above the orifice of the bile duct in the duodenal papilla without an anomalous pancreaticobiliary junction. Endoscopic ultrasonography showed a strong echo with an acoustic shadow in the diverticulum. These findings confirmed the diagnosis of intrapancreatic biliary diverticulum with a stone. Resection of the diverticulum with intrapancreatic bile duct, cholecystectomy and choledochoduodenostomy were performed safely. Excision is recommended treatment of biliary diverticulum. Therefore, even the intrapancreatic biliary diverticulum, resection of the diverticulum and intrapancreatic bile duct is the preferred treatment in most patients.

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