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1. Arch Surg. 2010 Jan;145(1):96-8. doi: 10.1001/archsurg.2009.236.

The pedicle effect and direct coupling: delayed thermal injuries to the bile duct after laparoscopic cholecystectomy.

Humes DJ1, Ahmed I, Lobo DN.

They mention timing namely 3-4 days, and clinical manifestations -pinhole leaks from bile duct.

2. This article classifies types of injury from many causes including thermal injury-

https://www.ncbi.nlm.nih.gov/books/NBK6928/

3. This article talks about many types of bile duct injuries, including thermal, and refers to the Bismuth classification -related to anatomy and severity.

https://pdfs.semanticscholar.org/c3ae/7d8a1e9b838a253ff496a7da35769c129861.pdf

4. This article discusses the classification of injuries (Bismuth)- and modifications (Strasberg-Soper)

https://www.med.mun.ca/getdoc/ca051cfe-75ae-4223-aff0-95d689aaf313/BileDuctInjuries.aspx

Hope this is the information you are requesting.

Dear Trevor.

Thank you so much.

I have met another type of thermal injuries.

In all cases it was common hepatic duct (above the cystic junction), in majority cases it was acute cholecystitis. In all my cases was late manifestation (within a year after the procedure) - stricture of the CHD.

I would like to share my hypothesis - the irrationally selected voltage / current strength during monopolar coagulation, uncontrolled conductivity of tissues, especially inflamed - edematous.

Thank you very much again.

I had one case of monopolar diathermy injury to CBD in a case of empyema GB, when a tiny arterial twig passing over the anterior surface of CBD was injured and bled. All other efforts failed leading me to use a soft short low current monopolar diathermy. Bleeding stopped but the patient came back after a fortnight with a huge upper abdominal swelling, painless, nontender and patient being afebrile. USG showed a huge liquid collection in subhepatic pouch. My instant conclusion was biliary leak encysted in subhepatic space. I stop here short as to how did I deal with it because the question in context is answered.

Dear Prakash.

Thank you for shareing your case. It is important case for me.

Sincerely, Vladimir.

Thank you dear Vladimir and welcome.

Mono polar cautery injuries are not very common but these do occur when attempts are made to stop bleeding from cystic or Hepatic artery.More commonly is due to transmitted energy on to cystic or bile duct which leads to sloughing of the duct 3-4 days later manifesting as Biliary leak/peritonitis.Most of these can be managed by ERCP +stenting and percutaneous drainage/Laparoscopic peritoneal wash.These need follow up and sometimes multiple stent exchanges/surgery.

Dear Prasanna.

Thank you for your attention to my question.Your answer is important to me.

Sincerely, Vladimir.

More often, it has been noted that even senior surgeons have very little knowledge about the physics of electrosurgery unit and its functions which will empower the surgeon to make safe use of the energy source. Yes, electrosurgical injury is uncommon but when occurs, can be dangerous and life threatening. I have seen such cases in the clinics of other colleagues. Hence a good theoretical knowledge about the physics of electrosurgery will go a long way to guard from such injuries. Earlier during the mid-twentieth century, such injuries were common and the laparoscopy was defamed and banned in Germany.

Dear Om Prakash.

Thank you very much. Do you think it is necessary to clearly limit the voltage when working with a monopolar coagulator, specifying the acceptable limits. Perhaps these restrictions exist.Are the permissible voltage values similar for different types of laparoscopic operations? Sincerely, Vladimir.

Dear Vladimir Khokha,

Thank you for your kind point. You see, different makes of electrosurgery units have different specifications, which may be difficult for any average surgeon to follow with little knowledge of working physics. As regards voltage, I try to keep it at as low as possible in majority of cases. It may differ with different makes due to their variety of issues that may be difficult for an average surgeon to remember conducting different surgeries. As you know, monopolar electrosurgery is highly potent energy source with its spread along its path of travel through the body to complete the electrical cercuit for its effectiveness. I try to modulate or increase the voltage during dissection if found ineffective in a given situation that may be difficult to quantify. Further the charred protein sticks to the tip of the electrode that also hampers the conductivity. This charred tissue protein must be scrapped with the blunt side of the surgical scalpel to freshen up its conductivity.

One must remember that the "density of electrical current" at the given point of time is more important than voltage and it depends upon the conducting tip of the electrode at the tissue level. Shorter and pointed is the tip, the density of electrical current shall be higher, given all other electrical parameters, i.e. voltage and frequency, etc. Hence the need for a good working knowledge of conduction of electrical current and know your own electrosurgical unit. If confronted with a new electrosurgical unit, kindly start working with lowest setting and discover the precise current voltage as well as the size of the dispersal tip of the instrument in use for electrosurgical effect on tissue. Hope it may help you.

With regards,

Dear Om Prakash. Thank you very much again.

You're absolutely right. For each specific device, there are characteristics, including current strength, frequency, voltage. I noticed, and it is obvious, the tissues differ in the conductivity of the current: serosa, fat or muscle tissue, there is edema and its severity, living tissue or necrotic and so on. Accordingly, it is possible, in the presence of severe inflammation, the cause of thermal damage to the CBD can be not direct contact during dissection, but indirect damage due to increased transmission of electrical energy (with stable voltage digits and in accordance with the instructions to the device )?

Sincerely, Vladimir.

We must keep our patient away from technological tyrany of modern scientific practice. As we all know that sophisticated techniques of endoscopy and laparoscopy are not easily available to patients in periphery, even in a country like India. Hence one must beware that try to make the first surgery the last surgery and make d best. For a surgeon, a patient may be a mere case but for the patient, it is his life and a huge economic burden that is hardly taken care of in under- or developping countries.

Dear Om Prakash.

Thank you very much. Each surgeon always trying to do his/her best for each patient.

Dear Om Prakash,

Thank you for an insightful and empathic perspective.

Dear Trevor.

Thank you indeed.

Dear Colleagues. Something on this topic. The result of the literature search, work experience allowed us to classify the thermal damage of the BD during LCE (in the attached file). Interested in your opinion.

The classification is very acceptable,for type one injuries also on table stenting is ideal.Reconstruction in a cauterised duct carries higher incidence of strictures as it is difficult to assess the thermal damage.i do realise emergency endoscopic facilities may not be available everywhere.If the stricture is stentable,it is better to try first.stent exchanges may take number of times.Ofcourse if the duct is dilated well,that is different scenario.

Dear Prasanna. Thank you so much.

You right. Stenting is not everywhere available, first, second, chronic cholangitis during endoscopic treatment also should be taken into account. Surgery on not dilated ducts is also controversal. But in general classification, I hope, can be useful, emphasizing the importance of thermal damage, even imperceptible during the primary operation.

Article Delayed Perforation of the Large Bowel due to Thermal Injury...

Thank you very much, Dear Ahmed.

I am collecting data on thermal injuries of bile ducts. Although the case you sent, corresponds the classification we proposed.

Sincerely, Vladimir.