Masjid Nabawi –dream destination for
any Believer
‫ن ّ وملئكت يصل ن عل نبي ي َيه لذ ن‬
َ ‫إِ ّ ا َ َ َ َ ِ َ َه ُ ُ َّو َ َ َى ال ّ ِ ّ َا أ ّ َا اّ ِي‬
‫ل‬
‫آ َ ُوا َّوا َ َيْ ِ َ َّ ُوا َسِْيم‬
‫من صل عل ه وسلم ت ل‬

“yeh bargahi habib haq hai-chalo saroon ko jhuka jhuka kar -durood har ik qadam pai
bejoo-niyazemandi dikha dikha kr”

My Vision
The right care for every person every time.

Strategies for Lowering the Rate of Bile Duct
Injuries in Laparoscopic Cholecystectomy

bile duct injuries
A Review --Mechanism, Preventive Measures, and Approach
to Management:;;Repair
When BAD THINGS HAPPEN TO GOOD
SURGEONS ? Why? …where?...who?
part1

•Quality Manager and Supervisor CME Surgery .
•Group leader ---JCI joint commission international for Hospital accreditation
Surgical chapter
•Editor ( Ass ; Rev ; Online ) international and Medical Journal - Minimal
access ,;
•. slidedworld . com ; ind jr of surgery
•–Literature review current through:. This topic last updated Feb 2012
Literature review current through: Feb 2012.
DR;FIAZ FAZILI –

This topic last updated: Jun 8, 2010

Congressman: Murtha Died
After Intestine Was
Damaged in Gall bladder
Surgery
 Rep. John Murtha (D-PA), the
first veteran of the Vietnam war
to be elected to Congress and
one of its most powerful
lawmakers, died Monday
afternoon at Virginia Hospital
Center in Arlington, Va., after
complications from gallbladder
surgery.
The gallbladder surgery was
performed days earlier at the
National Naval Medical Center
in Bethesda, Md

Present status of Post lap chole-biliary duct injuries-
A Quality Manager’s overview…

How can we improve? Debatable—Controversies & issues (policy)
. ARE WE Practicing –Safe surgery rules ?
.
P Who is doing What ,at What place ;and on Whom?...
t Is BDI following lap chole –prof negligence (Medical
malpractice) or risk inherant to procedure

 َ َ ِ ْ َ ‫َ َا ِن َآّ ٍۢ ِى ٱ‬
‫لْرض ول‬ ‫و م م د بة ف‬
‫طَ ئر يط ر بجن ح ه إل أمم‬
ٌ َ ُ ّٓ ِ ِ ْ‫َٓ ِ ٍۢ َ ِي ُ ِ َ َا َي‬
‫كتَب‬
ِ َ ِ ْ‫َمْ َا ُ ُم ۚ ّا َ ّطْ َا ِى ٱل‬
‫أ ث لك م فر ن ف‬
ْ‫ِن َىْ ٍۢ ۚ ُ ّ َِىَ َّ ِم‬
‫م ش ء ثم إل ر به‬
‫ي شر ن‬
َ ‫ُحْ َ ُو‬

 The Noble Quran- Al-
Anam (6:38)-

 There is not a moving (living)
creature on earth, nor a bird
that flies with its two wings,
but are communities like
you. We have neglected
nothing in the Book, then
unto their Lord they (all)
shall be gathered.

ollaboration among Surgeons, Gastroenterologists and
interventional Radiologists is imperative in the management of
such injuries

 A good story during the incidents, the
explosion of a plant in Nanjing, China on July
28, 2010 . Event of a crash that killed 13
people and injured 300 people tells a lot of
attention the fact that suck the public.
During the explosion occurred, a monkey was
recorded during the camera saves the puppy
from the explosion site. They hold the dog as
he ran out of the factory.

If this event can tap our collective conscience,
animals can show compassion and kindness to
each other.

Gensis powerful high explosive that occurs
when a pipe from burning chemical factory in
China. The explosions occurred in Nanjing,
Jiangsu provincial capital, about 10.00 am. In
addition to deaths and injuries, the explosion
also damaged the surrounding area. windows
of houses, shops and offices were damaged
and affect the extent to 300 meters. While
other people thought was an earthquake.

Case 1

A 55 years old male Yemeni. Had post-
cholecystectomy CBD injury.;Detected post
operative period ;Surgeon referred to Gastro
enterologist/.Dr.Fk,for evaluation /
management, from ,,,,,,,,(……. Hospital)
Dr. FK referred the patient for US esp-
Heaptobiliary area.Then he performed the
First ERCP for the Patient, in 9/12/2006

DR .Fazal I ;Khawaja , DR Abd Salam-Consultant & Head
Consulatant Gastrio -Enterologist interventional Radiology

PTC, showed a sealed biloma, at the GB bed ,
with no leak.

Trials for PTD down to the Duodenum for two
Hours

Suddenly, the guidewire slipped through down
to the Duodenum !!!?

ERCP and Radiology Imaging and Interventional
management of Peri op complication of Lap chole
are an effective Diagnostic and Therapeutic
modality. A great relief and help ..lap surgeon
The technical skill, experienced hand and good
knowledge of the different procedures are required
to increase success and limit complication rate.

“we [general surgeons]
had already lost
traditional surgical fields
like polypectomy,
papillotomy, and now
even endoscopic
appendectomy .
I was convinced that if
we passed up this
chance like endoscopic
cholecystectomy,
internists and
gynecologists would
again take away a piece
of our
competence….”Muhe

Picture of the abdomen of the first patient to have
laparoscopic cholecystectomy, September 12, 1985, showing
portholes in the lower abdomen.

 Basic pistol grip hemoclip applier and scissors made for W.
Reynolds, Jr, MD, in 1972.

 Mühe's open tube
laparoscopic
cholecystectomy,
Technique No. 2.
Patient with 1 access,
directly above the gall-
bladder without
pneumoperitoneum
because the costal
arch is a firm bone
roof.

The spectrum of mishap has also
changed due to the involvement of
new instruments/technique such as;
stapling device,hook scissors; & energized
instruments
New Complications like; migrating clips
or spillage of gallstone;thermal
injurues into peritoneal cavity were
completely unknown in open surgery.

Surgeons rushed in massive numbers to learn the surgery, taking weekend courses—to
add laparoscopic surgeon to their business boards. ;prescription pads

 1992 NIH safety approval Lap chole ----- An increase
from 0.1% to about 0.6% -5%(x10 times)
WERE been noted ;
 As of 2012, 0.4%..(OC—0.1-0.3% ).
 Expected drop in % significantly with
---time/experience.but…it didn’t happen

 Between 34% and 49% of surgeons are
susceptible (expected to )cause such an
injury during their career.

It was a plausible and logical argument that the
abrupt rise in bile duct injuries associated with the
earliest efforts to perform laparoscopic
cholecystectomy could be expected to drop
significantly once surgeons and residents
progressed beyond their own learning curve for this
novel technique.

Laparoscopic Bile Duct Injuries
• Bile Duct Injuries - Incidence
• Laparoscopic Cholecystectomy

- Deziel (1993) - 0.6%
- Wherry (1994) - 0.5%
- Wherry (1996) - 0.4%
- Nuzzo (2005) - 0.4%
- Waage (2006) - 0.4%
- Fazili (2010) - / 0.32 %
(0.40 / 0.32 / 0.47 )

Certainly, it has not been for a lack of research on laparoscopic
cholecystectomy. A Medline review found more than 20000 articles
published on the subject in 2001 alone. Perhaps processes in play,
unrecognized by surgeons, have prevented us from making progress in our
efforts against the learning curve.

 a) Doing the right thing right the first time only.
 b) Doing the right thing right the next time.
 c) Doing the right thing right the first time, doing it
better the next time---in all time.
 d) All of the above
 The answer is====C-Doing the right thing right the
first time, doing it better the next time---in all time.

 .)

Negligence or
An inherent
procedural risk-

Objective To apply human performance concepts in an attempt to understand
the causes of and prevent laparoscopic bile duct injury

These LESSON OFTEN
WE FORGET…

To improve our results, we need to
accurately identify the cause of our
mistakes-

Suggest RECOMMENDATIONS-..To apply human
performance concepts in an attempt to understand the
causes of and to prevent laparoscopic bile duct injury

Level I Evidence from properly conducted randomized, controlled trials

Level Evidence from controlled trials without randomization-Or
II Cohort or case-control studies Or
Multiple time series, dramatic uncontrolled experiments
Level Descriptive case series, opinions of expert panels
III

Scale Used for Recommendation
Grading
Based on high-level (level I or II), well-performed studies with uniform
Grade A
interpretation and conclusions by the expert panel
Based on high-level, well-performed studies with varying interpretation and
Grade B
conclusions by the expert panel
Based on lower level evidence (level II or less) with inconsistent findings and/
Grade C
or varying interpretations or conclusions by the expert panel

 Policy and procedures--
Who should do what ?
 Do we need to certify or
accredit,any hospital or
pvt nursing homes before
allowing them to…..lap
surgery????
 In case of bdi—is there
any written PROTOCOL,
Arrangement
 Do we need supervising body
of experts….for every splty for
monitoring.?

Safe surgeon

To this day, there are a lot of doctors performing this surgery
who should not be performing the surgery because they are
not qualified
Should we allow every one to do lap surgery -Who is so
called a ,”GoodSurgeon?”
What are basic requirements to allow lap chole to be done
by any Surgeon for any set up ?

"A good surgeon knows how to Reasonable knowledge
operate of Anatomy and fair use
A better surgeon knows when to of Instruments
operate
The best surgeon knows when not to
operate"

Qualified Certified for Open surgery

Accreditations-laparoscopy recognized center

Low threshold for conversion to open

Doesn’t hesitate to call for second opinion-transfer
to higher center

DO NO MORE HARM?-Respect s tissues- --Respect
tust Doesn’t hesitate to call for second opinion-
transfer to higher centerpatient rights.

There is increased rate of cholecystectomies after laparoscopic era?
Are we operating on right kind of patients or we have conflict in our interest ?
To operate or not to operate …on asymptomatic gall stone pts.

Indications Contraindications-
 “Most patients with symptomatic  Relative contra-indications
gallstones are candidates for lap for laparoscopic biliary
chole, ". Fit fr g/a; no tract surgery
comorbidities
 Untreated coagulopathy, l
 biliary dyskinesia,
 ack of equipment,
 acute cholecystitis, (calcukar
 lack of surgeon expertise,
or acalcular );
 hostile abdomen,
 Complications related To
CBD stones including ‫؛‬  advanced cirrhosis/liver
Pancreatitis failure, and
 Suspected gallbladder
cancer.
 Ebm=(Level II, Grade A).  Eivdence =(Level II,
Grade A).

 Asymptomatic
Did you know?
Majority of people with
gallstones: Should we
gallstones never experience operate?
any symptoms.  TO OPERATE OR
Others remain aysmptomatic (without
symptoms) for at least 2 yrs s after the NOT TO OPERATE ON
stone formation begins.
????Is there also a financial motivation that
ASYMPTOMATIC
If symptoms do occur, the chance of
GALLSTONES IN
attracts surgeons to this minimally invasive
developing pain is about 2% per year
for the firstprocedurethe stone LAPAROSCOPY ERA
10 yrs after (including a lot of gallbladder removal
formation, after which the chancepatients www.wals.org.uk/article.htm
procedures for for  that did not deserve
developing symptoms decrease. removal ?
 (Review article).
Risk of bile duct injury with  DR Fiaz Maqbool Fazili.
laparoscopic cholecystectomy is  #Asymptomatic gall stones
around 0.2%
do not require treatment.
(excp high risk grp)

11:6
There is no moving creature on
earth but its sustenance dependeth
on Allah: He knoweth the time and
place of its definite abode and its
temporary deposit: All is in a clear
Record.

(52:58
 "Surely Allah is the
Bestower of provision,
Lord of Power, the
Almighty".,)

Is the Main problem misperception of ductal anatomy—or Surgeon
related(“)Attitude of Surgeon”?

 Risk Factors
◦ Anatomical
◦ Anatomical variations (biliary and vasculature)
◦ Bleeding, scarring, obesity

◦ Laparoscopic inherent-
◦ Lack of Depth Perception, Tactile Feedback, Full Manual
Maneuverability—working on image

◦ Improper surgical approach –Improper Lateral retraction (insufficient or
excessive)
◦ 0 degree scope
◦ Approach plane too deep-too close to CBD-duodenum

◦ ATTITUDE__not sticking to rules of game.
◦ Lack of conversion to OC during difficult cases;

◦ Between 34% and 49% of surgeons are expected to cause such an
injury during their career.

Video assisted Lap -Operation is on image-lack
of tactile sensation,contrast and depth of
vision –(integrity of eye ;brain; tactile )
No camera X megapixels and chips can
replace human eye--

“so which of yourLord's bounties will you
two deny?Holy quran Ch AL – RAHMAN )

 In the open approach,  Standard exposure
the gallbladder and provided by laparoscopy
the biliary tree are distorts the normal
viewed from the top alignment of the
down, whereas in structures by laterally
laparoscopy the biliary retracting the gallbladder
structures are viewed and creating an angle in
head on- the common hepatic duct
(CHD)/common bile duct
(CBD).

Biliary anatomy variations
should be imprinted in the
minds of all surgeons
during lap chole

Anatomical
abnormalities

Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm
with common hepatic duct (15-25%); F,G,H. Medial cystic duct insertion
(10-17%). Uncommon variants: C. High fusion with hepatic duct; D. Fusion at
right hepatic duct; F. No cystic duct.

 Refers to common hepatic duct obstruction caused by
an extrinsic compression from an impacted stone in
the cystic duct
 Estimated to occur in 0.7-1.4% of all
cholecystectomies
 Often not recognized preoperatively, which can lead to
significant morbidity and biliary injury, particularly
with laparoscopic surgery

 The safety of
laparoscopic
cholecystectomy
requires correct
identification of
relevant anatomy.
(Level I, Grade A).

 Intraoperative
cholangiogram may reduce
the rate or severity of
injury and improve injury
recognition. (Level II,
Critical view of safety
Grade B).

 In the 1990s , high rate( 2% -5%) of biliary injury was
due in part to learning curve effect.
 A surgeon had a 1.7% chance of a bile duct injury
occurring in the first case and a 0.17% chance of a
bile duct injury at the 50th case.
Conflicting with above reports-
 @However most surgeons passed through learning
curve, “steady-state” reached , but there has been no
significant improvement in the incidence of biliary
duct injuries.
 Moore M.J.; Bennett C.L , The American journal of surgery 1995
@Mubasher H Khan et al Gastrointest Endosc 2007

.
 Excessive traction leading to tenting of the CBD is
another factor predisposing to clipping and ligation of
the bile duct, especially when performing an open
cholecystectomy.. Obesity and excessive fat in the
porta hepatic area also poses technical difficulties
and can predispose to bile duct injuries. [9]

Misperception IS THE MAIN PROBLEM

 The common bile duct
is mistaken for the
cystic duct and
transected. A variable
extent of the
extrahepatic biliary
tree is resected with
the gallbladder.

Cephalad traction on GB to tent the
CBD out of normal location, leading
to clip placement at the cystic duct-
CBD junction

 --Mistaking the common
bile duct for the cystic duct

Pulling forcefully/ duct-Cephalad traction up on
the GB when clipping the cystic duct  tenting
injury to the junction of the CBD & common
hepatic. Duct.to

 Inappropriate use of
electrocautery near or
around the CBD may
damage its axial blood
flow, leading to ischemic
damage to the duct and
late stricture formation
Thermal necrosisductal
tissue loss

 May lead to bile leaks or
delayed stricture

 Mechanical trauma can
have similar effects

 Local risk factors ; 15–35% of BDI
 Bleeding in Calot’s triangle, Severely Scarred or shrunken gall
bladder,. ;Inflammation -; Mirizzi’s syndrome ;Large impacted
gallstone in Hartmann’s pouch, Short cystic duct, Acute
cholecystitis, Acute biliary pancreatitis
 Abnormal biliary anatomy].
 Lack of Experience or overconfidence+++
 More than ½ (half) of all such injuries occurred during the so
called “easy” LC performed by an inexperienced surgeon . ]

 Male sex and prolonged surgery~ for more than 120
minutes -independent risk factors

Can we minimize it ?
—what are modifiable factors-?
Pt related –no ;
Equipment-Environment –(some minimum requirements)
Surgeon related—attitude-technique –-credentialing-
revalidation

RULES OF THUMB TO
HELP PREVENT BILE
DUCT INJURIES

Rules of thumb to help prevent bdi

 Adequate and proper training in a laparoscopic surgery,
delineation of biliary anatomy in Calot's triangle (critical view)
by careful surgical dissection, .
 if need be by intra-operative cholangiography (IOC), in difficult
cases ,
 Avoiding blind application of clips, cautery in case of bleeding
in the Calot’s triangle are some of the measures to avoid a BDI
 judicious use of electrocautery,
 The primary cause of error was visual perceptual illusion in
97% of the cases . Fault in technical skill was present in only
3% of injuries.
 [Br J surg and Am j surg 2005.2008).

 Attention to operative details (insufficient close or
deep plane)
 Stasberg’s critical view of safety
 Appropriate Handling of Gallbladder

 Careful use of diathermy

 Recognition of Biliary and Vasculature Anomalies

Dissection within
the triangle of
Calot to
demonstrate the
cystic duct and
artery clearly
entering the GB

Critical view of safety

 Surgeons with more experience have the lowest
complication rates
 Furthermore, credentialing for laparoscopic surgery is
now becoming a reality.
 Many institutions currently, or soon, will require proof of a
fundamental skill-set in basic laparoscopy for
credentialing purposes.
 (SAGES) have developed a validated assessment tool
named Fundamentals in Laparoscopic Surgery (FLS)].
 FLS is now required by the American Board of Surgery to
qualify for the surgical certification examination.

 IOC - may reduce the rate or severity of injury
and improve injury recognition. when used
routinely and allows access to the biliary tree
for therapeutic intervention; (Level II, Grade B).

• Routine IOC is technically challenging, adds cost and time
to the procedure & is unnecessary for the majority of
patients—
• Laparoscopic cholecystectomy without cholangiography: Is it a
safe procedure?
• O M Elhassan and F M Fazili Minim Invasive Ther 4(4):219 - 222 (1995)
•
• Few Surgeons selectively use preoperative (ERCP) and
perform IOC based on abnormal LFT or a dilated CBD
or /on preoperative USG.


 Intraoperative
cholangiogram shows
filling of distal bile duct
with flow into the
duodenum. The lack of
retrograde flow into the
proximal biliary tree is
concerning. A clip may
be present occluding the
bile duct proximally.

 Dome down technique-- Dissection of the
gallbladder from the liver bed:The more
conventional approach starting at the
gallbladder infundibulum and working
superiorly, or the top down approach, may be
used with electrocautery, ultrasonic
dissection, or hydrodissection as the surgeon
prefers.
 Level II, Grade B).
 Percutaneous and open cholecystostomy
 Partial cholecystectomy
 CONVERSION TO OPEN

 Conversion should not be
considered a complication and
surgeons should have a low
threshold for conversion;
 Decision to convert to an open
procedure must be based on
intraoperative assessment
weighing the clarity of the anatomy
& the surgeon’s skill/comfort in
proceeding.

Use of the checklist reduced the rate of deaths and
complications by more than 1/3 across all 8 pilot
hospitals. (Canada;India; Jordan;;NZ;;Philiphine ;Tnazania; Uk; ;USA)

The rate of major inpatient complications dropped from
11% to 7% after implementation of the checklist. at
essentially no cost to the system..

CHECK YOUR TYRES BEFORE ANY JOURNE Y--

 Type A ;Cystic duct leaks
or leaks from small ducts
in the liver bed
 Type B ;Occlusion of a
part of the biliary tree,
almost invariably the
aberrant right hepatic
ducts
 Type C; Transection
without ligation of the
aberrant right hepatic
ducts
 Type D; Lateral injuries to
major bile ducts
 Type E ;Subdivided as per
Bismuth classification into
E1 to E5

 E: injury to main
duct (Bismuth)
 E1 : Transection

>2cm from
confluence
 E2 : Transection
<2cm from
confluence
 E3 : Transection in
hilum
 E4 : Seperation of
major ducts in hilum
 E5: Type C plus injury
in hilum

Co-mmunicate with patient and /or relatives

Bile Duct Injuries
• How do you get Suspicion DURING OR—(intra
operatively)

• Atypical anatomy

• “Accessory” duct

• Unsuspected bile leakage

• Abnormal cholangiogram

 Only 25-33% of injures are recognized intraoperatively
1. Expertise available ; Convert to Open Procedure and
perform Cholangiography or vice versa (determine extent of
injury) and accordingly --treat
2. Experitise not available ;Perform the cholangiogram
laparoscopically with intent of referring patient (placement
of drains);
1. Consult an experienced Hepatobiliary surgeon;
2. Quicker the repair, the better the outcome!!!

 Acute Management-do no more harm----Drain the bile- Sepsis
control
 Biliary catheter for decompression of biliary tract & Control of bile
leaks
 Percutaneous drainage (US/CT) of intraperitoneal bile collection

 The classic injury is when the CBD is mistaken for the
cystic duct. Once the gallbladder has been removed, it is
important to recognize that more than one
structure has been injured, and the repair is
complex.
 The goal of reconstruction is to avoid cholangitis, cirrhosis
and stricture.
 In the presence of an injury, it is important not to panic,
leave the patient well drained to control the
leak, and refer to an experienced hepatobiliary
surgeon.
 Finally, if an injury should occur, an experienced
hepatobiliary surgeon should make the repair;
this will greatly impact the rate of complications and the
long-term success of the repair.
 Timing-- Data suggest that repairs performed early or
after six weeks of the injury have better outcomes

 Patient presents with…clinically
 Vague abdominal pain, nausea, fever, jaundice, vomiting

 Investigation
 Blood –lft.cbc;kft
 Ultrasonagraphy and CT (ductal dilatation and intra-abdominal
collection)
 Cholangiogram
 ERCP—biliary anatomy and assess the injury
 PTC—define biliary anatomy proximal to injury
 MRCP—noninvasive (can miss minor leaks)
 HIDA scan--
 MR angiography—vascular injuries

 HIDA – presence of
active bile leak
(physiologic

US/CT – detect bilomas + Per cut Drainage)

 Provides exact anatomical diagnosis of bile duct leak;
while allowing treatment w/ decompression of the
biliary tree.
 Principal of treatment is to establish a pressure
gradient that will favor flow into the duodenum not
the leak site; may entail removal of retained stone or
internal stenting +/- sphincterotomy
 Internal stenting is currently the procedure of choice
for treating bile duct leaks ( types A & D)

 Cessation of bile extravasation in 70-95% of cases
w/in 7 days

POST-OPERATIVE BILE LEAKS &
BILIARY FISTULAS

Limitations of ERCP—PTC –MRCP superior but non therupetic
Inability to visualise the biliary tree beyond the obstruction
Bilomas might need percutaneous drainage

PTC

POST-Lap chole
BILE LEAKS & BILIARY
FISTULAS : ROLE OF ERCP=good
gastroenterologist is a help

;
Fazal Khawaja,
-
Gastroenterology
King Fahad Hospital
Al Madina Al Munawarah.

Our experience (15yrs)
Lap – Chole Related Bile leaks:
Cystic duct stump 27(40%)
Duct of Lushka 8(12%)
Main Bile duct ( no luminal
narrowing or obstruction) 5(7.5%)
With main Bile duct injury 8(12%0
(convert to open = 6)
MBD Inj + no leakage in ERC 19(28%)
Total=67/171

ERCP helps in diagnosis and removes any doubts regarding possible major ductal injuries.
The condition resolves spontaneously ] provided there is no distal obstruction; the process
may be hastened by the placement of a stent endoscopically.

Site of bile leaks:
Duct of Lushka (DOL)

Bile leaks with luminal
narrowing of MBD

Careful flouroscopic observation of leakage point of origin

An un-experienced & poorly equiped Endoscopist is the
surgeons worst enemy
To have a complication is bad luck but to mismanage it is
Bad Medicine

Figure 2: MRCP revealing subhepatic and
significant intra-abdominal bile collection from
cystic duct leak. The CBD is not dilated. The
patient was managed effectively with ERCP
Figure 1: ERCP showing small CBD leak managed sphincterotomy.
effectively by sphincterotomy

POST-OPERATIVE BILE LEAKS &
BILIARY FISTULAS
Limitations of PTC and ERCP
Inability to visualise the biliary tree beyond the obstruction
MRCp is diagnostic-shows both ends but is not therupetic
Bilomas might need percutaneous drainage
ptc

 examine the source of bile leak
 Although bile may leak from an opening in the GB or the cystic
duct, before that is presumed to be the case, BDI should be
ruled out. Bile from GB is greenish yellow, thick, and viscid,
whereas common bile duct (CBD) bile usually is bright yellow,
thin, and watery.
 An IOC at this stage may delineate the anatomy and prevent
any further injury to the bile duct.
 A BDI should also be suspected if a third tubular structure
(after cystic duct and artery have been clipped and divided) is
encountered in the Calot’s triangle. The “cystic duct” which was
clipped and divided earlier may actually have been the CBD
and the third structure now being encountered may be the
common hepatic duct.
 If the BDI is recognized intraoperatively, the management
depends on the nature of the duct injured, type of injury, and
the expertise and experience of the surgeon

 Type-magnitude
 Expertise availbility
 Bile leak-Partial-Complete
 Bile-Obstruction ;clipping;
 Management differs

 The goal of surgical repair of the injured biliary tract is
the restoration of a durable bile conduit, and the
prevention of short- and long-term complications such
as biliary fistula, intra-abdominal abscess, biliary
stricture, recurrent cholangitis and secondary biliary
cirrhosis.
 The ease of management, operative risk, and
outcome of bile duct injuries vary considerably and
are highly dependent on the type of injury and its
location. For this, a classification bearing therapeutic
and prognostic implications is needed.

 Controlling sepsis, establish biliary drainage, postulate
diagnosis, type and extent of the bile duct injury.
 Broad-spectrum antibiotics
 No need for an urgent laparotomy. Biliary reconstruction in the
presence of peritonitis results a statistically worse outcome in
patients.
 No need for urgent with reconstruction of the biliary tree. The
inflammation, scar formation and development of fibrosis take
several weeks to subside.
 Reconstruction of the biliary tract is best performed electively
after an interval of at least 6 to 8 weeks.

Site of bile leaks:
Cystic duct +Stent

 Injury to a major duct (right hepatic
duct/CHD or CBD) has more serious consequences. In
the event of this unfortunate incidence, further
management including assessment would depend on
the availability of expertise
 . Expertise Available
 In an ideal situation, a trained biliary
surgeon with adequate experience in reconstructive
biliary surgery should carry out the repair. The
procedure should be converted to an open operation,
and the injury should be repaired as detailed
subsequently.

 A lateral/incomplete injury (involving partial
circumference of the duct) may be repaired with fine
(4-0/5-0) suture of vicryl/PDS. Some recommend the
placement of a T tube as a stent.
 However, the placement of a T tube in an undilated
normal size duct may be difficult and frustrating and
could potentially aggravate the injury

 If the duct has been divided,
 it is important to assess if there is associated loss of
a segment of the duct as happens in the classical
lap cholecystectomy injury
 This happens when the CBD is first clipped and
divided mistaking it for the cystic duct. CHD is then
encountered and divided again.
 The ideal management of a complete
transection of the bile duct is the restoration of the
biliary enteric continuity with a Roux-en-Y
hepaticojejunostomy
.

 When the bile duct has been divided without excision of
a segment, a primary end to end anastomosis of the cut
ends of bile duct has been described. This procedure
had fallen into disrepute after a report stating that
almost half of such repairs developed into strictures that
later required hepaticojejunostomy.
 . A distinct advantage of this procedure is that it
maintains the normal biliary drainage into the
duodenum and avoids the risk of reflux associated
cholangitis and stricture following hepaticojejunostomy.
 Another advantage of the repair is that the stricture that
might result is usually of a low variety (Bismuth Type 1
or 11). These are more easily repaired surgically in the
event of failure of endoscopic and radiological
intervention

 in such situations no attempt must be made to repair the injury. Repairs
done by inexperienced surgeons are likely to fail.
 In addition, repair after a previous attempt even if done by an expert biliary
surgeon is less likely to be successful

 The safest option (in the interest of both the patient and surgeon) is to
irrigate the area with copious amounts of solution, observe and record the
operative findings and place two large/wide bore (28 French) drain in the
subhepatic fossa [
 This will drain the bile from the injured duct and prevent the formation of a
bilioma. Omentum if available may also be placed in the subhepatic fossa.
This can be accomplished laparoscopically and there should be no need to
convert to laparotomy. This will result in a controlled external biliary fistula,
thus preventing peritoneal sepsis .
 Postoperatively an endoscopic papillotomy may be performed and a stent
placed in the CBD in cases of partial injury to decompress the bile ducts
 The external biliary fistula may eventually close without any biliary
obstruction in case of partial injury. In some cases especially those with
complete injury, the biliary fistula may not close and repair will need to be
performed using the undilated proximal ducts

 In the majority of cases (more than 60%), the biliary injury is unrecognized
at laparoscopic cholecystectomy
 A high index of suspicion is essential to recognize biliary injury (leak or
transaction of CBD) in the early postoperative period.
 the most common site of leak included cystic duct stump (78%), a
peripheral right hepatic duct (Luschka 13%), and other sites like common
bile duct and T tube insertion point (9%) [In a study of 2007 post ercp)
 The leak could either be low grade (LG) where the leak is noted only after
the opacification of the intrahepatic biliary radicles with contrast following
ERCP or a high-grade leak (HG) when the leak is observed fluoroscopically
before intrahepatic duct opacification [
 The later is considered more significant as the spillage of contrast occurs
with minimal injection pressure and before the opacification of the ductal
system. Patients with LG leak are effectively managed by sphincterotomy
alone or placement of nasobiliary tube or stent placement, and it could
achieve reduction in pressure gradient and allow closure of leak in >90%
 HG leak however would require stent placement with probably bridging the
site of leak-like cystic duct stump leak. Decision of stent placement is
however determined by the severity of leak rather than site of leak [12].

 If there is no bile leak, the patients may not have any
symptoms and signs in the early postoperative period and
may develop jaundice after an uneventful discharge from
the hospital.
 Therefore, a follow-up visit approximately 1 to 2 weeks
after cholecystectomy is desirable. Some BDIs especially
ischaemic may present several months or even years after
cholecystectomy .
 The management of injury detected after discharge from
the hospital should be performed at a center with
appropriate expertise outlined previously.
 The procedure of choice for repair of a major
duct injury or stricture is a hepaticojejunostomy [.

 More often a biliary stricture develops (with dilated proximal
ducts) which will require a hepaticojejunostomy. Placement of
a tube into the proximal end of the divided duct to convert the
BDI into a controlled external biliary fistula is attempted by
some. The attempt to place a catheter into the injured
nondilated proximal duct during the course of a laparoscopic
cholecystectomy may, however, cause further injury to the
CHD, particularly when performed by an inexperienced
surgeon.
 Clipping of the divided duct is sometimes performed with
intent to prevent bile leak and allow the injured duct to
stricture resulting in the proximal duct dilatation which
facilitates a hepaticojejunostomy .
 This is rarely successful because in the majority of cases the
clipped or ligated ducts sloughs, thus causing the inevitable
bile leak and resulting in the injury becoming even more
proximal. Moreover, the clip (or ligature) also interferes with the
blood supply and causes ischaemic injury

 Hepaticojejunostomy is preferred to choledochoduodenostomy as
the latter is prone for complications due to reflux cholangitis [ref 5, 9,
33].
 Hepaticojejunostomy with Roux-en-Y anastomosis reduces the
tension of anastomosis and provides good blood supply and is the
preferred option to treat duct transection injury [5, 9, 26–28, 33].
 It is also the procedure of choice to treat duct defect and strictures.
 The outcome is significantly influenced by the surgical technique
especially when the duct is not dilated [27, 28].
 The outcome is better when one layer end to end anastomosis with
5-0 absorbable suture is carried out with the loop for bile drainage

longer than 50cms to avoid reflux and infection [5, 9, 26–28, 33].
 The dead tissue at the end of the duct should be debrided [26, 28].
Some would place a temporary stent tube through the area of
reconstruction when the duct is small. The tube helps to perform the
anastomosis while permitting to perform cholangiography to check
in a week or so, and it may serve as a drain if the anastomosis is
temporarily leaking. The use of a transanastomotic stent is, however,
debatable [25, 26].

Side to side –anastomosis –bismuth II or III

Outcome results

Why?
Results by an expert- and results by an routine

 The best outcomes
 Early repair (72 hours after LC-BDI)
 late repair (>6 weeks after LC-BDI).
 A minor comment is that an interval between 0 and 72 hours after LC-
BDI has an unclear meaning:
 0 hours suggests intraoperative repair,
 Most important, within the intermediate timing of repair (from 72 hours to 6 weeks
after LC-BDI), a critical distinction should be made between the presence of a clean
surgical field (ie, complete common bile duct stenosis with obstructive jaundice, without
bile spillage) and a field that is inflamed or infected by bile.
 We believe that in the former case, surgical repair would occur in an ideal condition
within 2 weeks following LC-BDI, . .

 EXPERT VS NORMAL ; Successf rate when Surgery performed by/at
 Primary surgeon =35%
 Specialized Expert( hepatobiliary surgeon)=>90 %, (John
Hopkins Group –99 )
 Timing– of Repairs ;Early or after 6 weeks of the injury have
better outcomes than those repaired in the intermediate period.

 Contirb factors for outcome- active peritonitis , assoctd vascular injury, the level
of injury at or above the biliary bifurcation, and no.of previous operations

Suggested flow diagram for patients with suspected bile duct injury
after laparoscopic cholecystectomy [3].
Manouras et al. Journal of Medical Case Reports 2009 3:44
doi:10.1186/1752-1947-3-44

 Timing of diagnosis;Expertise availability; SEPSIS ETC

 Endoscopic stenting for strictures

 T-tube placement for minor lacerations

 Primary duct-to-duct repair only if tension free anastomosis
available

 Biliary anastomosis with jejunal loop for major excisional
injuries

Safe Surgery Saves Lives Frequently

An error during gallbladder surgery ) is a common source of
medical malpractice claims, largely because this is a common
form of surgery. Most malpractice claims from gallbladder
surgery occur when a surgeon does not know where the biliary
ducts are on a patient and cuts where the surgeon should not be
cutting.

Experience vs carelessness
Can an experienced surgeon using ordinary care cut this
common bile duct? The answer is almost certainly yes.

“it is the same surgeons who are “frequent flyers” in
malpractice claims involving common bile duct injuries.”-
malpractice lawyer

 Another common defense is the “patient had unusual
anatomy” or “he/she was too fat to be able to see”
defenses. These are slightly more saleable defenses
in some cases but usually it is a reflex surgeons being
sued for malpractice use in every case.
 Typically, there is nothing to suggest unusual anatomy
and no explanation as to why the doctor did not try to
use a cholangiogram (which malpractice cases rarely
involve) to figure out what belonged where.

 Professional negligence is defined as absence of reasonable
care and skill or willful negligence of a medical practitioner in
the treatment of a patient, which causes bodily injury or death
of patient.
 A doctor is not liable if he exercises reasonable skill and care,
provided that his judgment conforms to accepted medical
practice and does not result in an error of omission.
 The doctor cannot be sued for professional negligence, when
statistics show that accepted methods of treatment have been
employed on the patient and that the risk and injury which
resulted are of a kind that may occur even though reasonable
care has been taken.
 Present position----The usual misperception error
underlying laparoscopic bile duct injuries does not meet
the defining criteria of medical negligence

 Bile duct injuries are a major complication of both open cholecystectomy
and LC. It can have devastating effects, turning the individual into a "biliary
cripple".

 They mainly result from anatomical anomalies ‘local factors and errors of
human judgment and are thus preventable to some extent.

 The costs are reduced and outcome improved if these injuries are
diagnosed early (during operation or the early postoperative period). And
handled by experienced biliary surgeon;Int rRadiologist
;;endoscopist (ERCP)Team)

 Adding the experience gained from open cholecystectomy on the one hand
and the advantages of certification and revalidation in LC to improve
surgical techniques ;modifications in terms of visualization and
magnification on the other, will help in reducing the incidence of such
complications.


What model should exist in health
care?
 It is argued that not one model
of accountability fits all of health
care.
 Health care is too complicated,
with too many parties, with too
many complex relationships for
just one model.
 Stratified model of
accountability? Tailored to local
conditions….

(Emanuel & Emanuel, 1995)

“Despite numerous publications
on this topic, there is no simple
QUOTE OF THE DAY
set of rules that inexperienced
surgeons can follow in order to
avoid such a complication. When
it comes to experienced
surgeons, we all know it is
hard to teach humility.”

Ist and last Message
=“first do no harm ”
-- e very student in medical school takes

 "There is no moving creature
on earth but its sustenance
depends on God: He knows
the time and place of its
definite abode and its
Temporary deposit: All is in a
clear Record"……… Qur'an,
Hud, 11: 6
 The Bestower of Provision ,
Allah(SWT), the Almighty
says: "Surely Allah is the
Bestower of provision, Lord of
Power, the Almighty".Noble
Qur'an (52:58)

I am the Boss- I am the BEST –dnt know …
Why This arrogance?.....in this world ------

Background to Safe Surgery Saves
Lives

 The author is indebited to those contributors whose
pictures have been shared with readers here for
purely academic purposes to benefit processionals
and patients(humanity at large ……..) and there is no
conflict of interest directly or indirectly except pure
academic reminders in bringing this material-to help
prevention of this complication ---and in case anyone
has his/her objection –the author will immediately
delete that ….material-- thanx

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