5. Risk factors
Inflammation in the porta,
Variable biiary anatomy,
Inappropriate exposure,
Aggressive attempts at hemostasis,
Surgeon inexperience.
97% due to visual misperception, only 3% accounts for
technical skills and knowledge.
6. Misperception ..
With sufficient cephalad retraction of the gall bladder fundus ,the cystic
duct overlies the common hepatc duct running in a parrellel path.
without inferolateral traction of the gallbladder infundibulum to
dossociate this structures, the dissection of apparent cystic duct may
actually include CBD…
8. Laparoscopic cholecystectomy (LC)
Gold standard for management of benign gallbladder disease
Compared with laparotomy
Less post-op pain
Shorter hospital stay
Earlier return to normal activity
Better cosmesis
Iatrogenic bile duct injury rate
0.1% to 0.2% (open) vs 0.4% to 0.6% (lap)
‘’Learning curve phenomenon’’
9. LC & Bile duct injury (BDI)
LC most common cause of BDI
More severe than those seen with Open chole
’Learning curve phenomenon’’
BDI after LC stable around 0.6 to 0.7%, 4 times that of open
chole – high for a benign condition
10. Classification
location of injury
mechanism & type of injury
effect on biliary continuity
timing of identification
Each plays significant role in determining appropriate
management & operative repair
11. Classification of BDI
Bismuth classification (1982)
Era of Open Chole
Based upon level of biliary strictures with respect to hepatic
bifurcation
Type 1-5.
Helps surgeon choose appropriate site for repair
Degree of injury correlates with surgical outcomes
12. Strasberg classification(1995)
Type Criteria
A Leak from Cystic duct or small ducts in liver bed
B Injury to sectoral duct(aberrant RHD) with obstruction
C Injury to sectoral duct with consequent bile leak
D Lateral injury to extrahepatic duct
E1 Transection >2 cm from the confluence
E2 Transection <2 cm from the confluence
E3 Transection at the confluence
E4 Separation of major ducts in the confluence
E5 Complete occlusion of all bile ducts.
14. Clinical Presentation (post-op)
Obstruction
Clip ligation or resection of CBD obstructive
jaundice, cholangitis
Bile Leak
Bile from intra-op drain or
More commonly, localized biloma or free bile ascites /
peritonitis, if no drain
Fever,abd pain , jaundice, or bile leakage from incision.
Diffuse abdominal pain & persistent ileus several days
post-op high index of suspicion possible
unrecognized BDI
16. Reasons
Misidentification
CBD or aberrant RHD mistaken for cystic duct
Risk factors inexperience, inflammation or aberrant
anatomy
Infundibular technique – flaring of cystic duct as it
becomes infundibulum misleading in inflammation
Technical errors
Cautery induced injury
17. Prevention
30° laparoscope, high quality imaging equipment
Firm cephalic traction on fundus & lateral traction on
infundibulum, so cystic duct perpendicular to CBD
Dissect infundibulo-cystic junction
Expose “Critical view of safety” before dividing cystic duct
Convert to open, if unable to mobilise infundibulum or
bleeding or inflammation in Calot’s triangle
Routine intra-op cholangiogram
“Fundus-first” dissection
18. Critical view of safety
Calot’s triangle dissected free
of all tissue except cystic duct
& artery
Base of liver bed exposed
When this view is achieved,
the two structures entering GB
can only be cystic duct &
artery
19. Cystic duct or CBD?
Cystic duct CBD Caution
2 – 3mm wide 5mm wide CD > 5mm – Is it CBD?
Even with low cystic
duct insertion, CD
rarely goes behind
duodenum
CBD goes behind
duodenum
Duct behind duodenum
must be CBD
Double cystic duct
very rare
-- 2 ducts seem to go towards
inflammed Gallbladder –
one must be CBD
No vessels on
surface
Vessels on
surface
--
21. Recognized at the Time of Cholecystectomy
Conversion to an open operation and use of
cholangiography.
Goals ..
Maintenance of ductal length, elimination of any bile
leakage that would affect subsequent management, and
creation of a tension-free repair.
22. Ducts smaller than 3 mm drain only a single segment or
subsegment of liver..simple ligation.
Ducts larger than 3 mm usually drain more than a single
segment of liver,if transected.. should be reimplanted into
the biliary tree.
Injury occurs to a larger duct, but is not caused by
electrocautery and involves less than 50% of the
circumference of the wall, a T tube placed through the
injury
23. Low injuries to the bile duct can be reimplanted into the
duodenum.
Most injuries to the bile duct occur higher in the biliary tree,
close to the hilum, thus not allowing for tension-free anastomosis
to the duodenum. Therefore, in almost all cases of bile duct
injury, a resection of the injured segment with mucosa to
mucosa anastomosis using a Roux-en-Y jejunal limb (end-
to-side choledochojejunostomy ) is preferred.
Transanastomotic stenting has been shown to improve
anastomotic patency.
24. Identified After Cholecystectomy
Goals of Therapy in Iatrogenic Bile Duct Injury
1.Control of infection limiting inflammation
Parenteral antibiotics
Percutaneous drainage
2.Clear and thorough delineation of entire biliary anatomy.
MRCP/PTC , ERCP
3.Re-establishment of biliary enteric continuity
Tension-free, mucosa-to-mucosa anastomosis
Roux-en-Y hepaticojejunostomy
Long-term transanastomotic stents if involving
bifurcation or higher
25. Approach..
Should undergo imaging to assess for a fluid collection and
evaluate the biliary tree.
Ultrasonography can achieve both these goals.
Cross-sectional imaging via CT will generally provide more
useful data.
Radionucleotide scanning to confirm bile leakage, but with
any documentation of a leak, CT will be necessary to plan
management.
26. CT or U/S guided (or surgical) drainage
Sepsis control Broad-spectrum antibiotics &
percutaneous biliary drainage to control any bile leak
most fistulas will be controlled or even close.
1.5% mortality rate due to uncontrolled sepsis
No rush to proceed with definitive management of BDI.
Delay of several weeks allows local inflammation to resolve
& almost certainly improves final outcome.
27. Definitive management is to reestablish durable biliary
enteric drainage.
Combination of percutaneous and endoscopic biliary
dilations and stenting may establish continuity.
Surgical reconstruction has the highest patency rates.
performed between a minimally inflamed bile duct to
intestines in a tension-free, mucosa to mucosa fashion.
28. If the anastomosis is within 2 cm of the hepatic duct
bifurcation, or involves intrahepatic ducts, long-term stenting
appears to improve patency
If the bifurcation is involved, stenting of both right and left
ducts should be performed
When the reconstruction involves the common bile duct or
common hepatic duct more than 2 cm from the bifurcation,
stenting is not necessary.
29. Interventional Radiologic and Endoscopic Techniques
Using balloon dilation techniques, the stricture is dilated and
a catheter is left in place to decompress the system, allow
healing, document resolution and, if necessary guide repeat
dilations.
This approach is successful in up to 70% of patients.
Endoscopic balloon dilation of bile duct strictures is generally
reserved for those with primary bile duct strictures or patients
who have undergone choledochoduodenostomy for
reconstruction, because the Roux limb does not usually allow
for endoscopic strategies.
31. ERCP – multiple stents
Lateral duct wall injury or
cystic duct leak
transampullary stent controls
leak & provides definitive
treatment
Distal CBD must be intact to
augment internal
drainage with endoscopic
stent
32. ERC – clips across CBD
CBD transection
normal-sized distal CBD
upto site of transection
Percutaneous transhepatic
cholangiography (PTC)
necessary
Surgery
33. Cholangiography (ERCP + PTC)
Percutaneous transhepatic cholangiography (PTC)
Defines proximal anatomy
Allows placement of percutaneous transhepatic biliary
catheters to decompress biliary tree treats or
prevents cholangitis & controls bile leak
34. MRCP / CT cholangiography
Noninvasive
May avoid invasive procedures like ERCP or PTC
Do not allow intervention
Interpretatation in presence of bile collection difficult
35. Biliary enteric anastomosis
Most laparoscopic BDI –
complete discontinuity of
biliary tree
Surgical reconstruction,
Roux-en-Y
hepaticojejunostomy
tension-free, mucosa-to-
mucosa anastomosis with
healthy, nonischemic bile duct
36. Treatment summary
Strasberg Type A – ERCP + sphincterotomy + stent
Type B & C – traditional surgical hepaticojejunostomy
Type D – primary repair over an adjacently placed T-tube (if
no evidence of significant ischemia or cautery damage at site
of injury)
More extensive type D & E injuries – Roux an-Y
hepaticojejunostomy with biliary stent
38. Reasons
Misidentification
CBD or aberrant RHD mistaken for cystic duct
Risk factors inexperience, inflammation or aberrant
anatomy
Infundibular technique – flaring of cystic duct as it
becomes infundibulum misleading in inflammation
Technical errors
Cautery induced injury
39. Anatomic illusion?
Misperception (97%) rather than technical error (3%)
Everyone is susceptible – experience, knowledge & technical
skill alone may not be adequate
All BDI may not represent “substandard practice”
Improvements may have to depend on technology
40. Summary
Multidisciplinary management of BDI expertise of
surgeons, radiologists & gastroenterologists
Mismanagement lifelong disability & chronic liver
disease
BDI with lap. Chole results of operative repair is
excellent in Specialist Centres
