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First planned cholecystectomy in the world was
performed by Carl Langenbuch in 1882.
First choledochotomy was performed by Couvoisser
First iatrogenic bile duct injury was described by
Sprengel in 1891.
Prof. Dr. Med Erich Muhe of Boblingen, Germany,
performed the first laparoscopic cholecystectomy in
a. Right hepatic duct.
b. Left hepatic duct.
c. Common hepatic duct.
d. Portal vein.
e. Hepatic artery.
f. Gastroduodenal artery.
g. Right gastroepiploic artery.
h. Common bile duct.
i. Fundus of the gallbladder.
j. Body of the gallbladder.
l. Cystic duct.
m. Cystic artery.
n. Superior pancreaticoduodenal
Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy
Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said
that anomalies are rule, not the exception.
( Maingot’s abdominal operations)
bounded by cystic duct,
cystic artery, and common
bounded by gallbladder wall
and cystic duct, liver edge,
and common hepatic duct;
the cystic artery (and hence
Calot's triangle) lies within
(Maingot’s abdominal operation)
Laparoscopic cholecystectomy Pros
Shorter stay in hospital
Faster recovery period
Reduced post-op recovery time
Less postoperative pain
Improved cosmetic outcome
Increase in serious bile duct complications and
Open cholecystectomy was standard practice for
treatment of symptomatic gall bladder disease until
At present 90% of cholecystectomies performed by
LC which is one of the commonest surgical procedure
widespread application of LC led to concurrent rise
in incidence of major bile duct injuries (BDI),which
are more complicated than after open procedures.
Since its introduction and routine use in 1990s, the
incidence of biliary injuries has doubled from 0.2%
Classic Laparoscopic Injury
Mistaking common bile duct for the cystic duct
near biliary ducts
May lead to
can have similar
Lahey Clinic, Burlington, MA.1994
Bile duct injuries during
In 1990s, high rate of biliary injury was due to
learning curve effect.
Surgeon had 1.7% chance of a bile duct injury
occuring in first case and 0.17% at the 50th
However most surgeons passed through
learning curve, steady – state reached, but
there has been no significant improvement in
the incidence of biliary duct injuries.
Biliary Injuries during Cholecystectomy
Open cholecystectomy has been associated
historically with 0.2% to 0.5% risk of postoperative
Biliary tract injuries.
On other hand LC has been associated with 2.5-fold
to 4-fold increase in the incidence of postoperative
BDI compared with OC.
These preventable injuries can be devastating,
increasing morbidity, mortality, and medical
cost, while decreasing the patient’s quality of
Biliary injuries will always exist, and we need
to be aware of the best methods to avoid,
evaluate, and treat them.
Incidence of IBDI following cholecystectomy (%)
Author IBDI incidence following
IBDI Incidence following
Mc Mohan et al,1995 0.2 0.81
Strassberg et al, 1995 0.07 0.5
Shea et al,1996 0.19-0.29 0.36-0.47
Targarona et al, 1998 0.6 0.95
Lillemoe et al, 2000 0.3 0.4-0.6
Gazzaniga et al, 2001 0.0-0.5 0.07-0.95
Savar et al,2004 0.18 0.21
Moore et al,2004 0.2 0.4
Misra et al,2004 0.1-0.3 0.4-0.6
Gentileschi et al,2004 0.0-0.7 0.1-1.1
Kaman et al,2006 0.3 0.6
Risk Factors for Biliary tract injury
Surgeon related factors
Lack of experience (learning curve)
Misidentification of biliary anatomy
Lack of recognition of anatomical variations of biliary
Improper interpretation of IOC
Improperly functioning equipment
Risk for biliary tract injury
Acute and chronic cholecystitis
Long standing recurrent disease -> fibrosis
The Effect of Acute Cholecystitis on Lap.
Complication rate three times greater than for
Early cholecystectomy (72 h) outcome better
than delayed cholecystectomy.
Conversion rate to open cholecystectomy is
higher than elective cholecystectomy 35% vs
Risk Factors for biliary tract injuries
Present in 18 – 39% cases
Dangerous variations predisposing to BTI are present in only 3-6% of cases
Abnormal biliary anatomy
Short cystic duct, cystic duct
entering in the right duct-
Accessory right hepatic duct
Right hepatic artery running
parallel to the cystic duct
Anomalous or accessory right
(Sabiston text book of surgery 19thedtn.)
Summary of Causes of Bile Duct
Common bile duct
Common hepatic duct
An aberrant duct (usually on the right side)
Technical failure such as
Slippage of clips placed on the cystic duct
Inadvertent thermal injury to CBD
Tenting of CBD during clip placement
Disruption of a bile duct entering directly into gallbladder fossa .
(Goal of dissection should be conclusive identification of cystic structure within
(If the cystic duct and cystic artery are conclusively and correctly identified before
dividing, more than 70% of bile duct injuries would be avoided )
Four methods of identification of cystic structures
1) Routine cholangiography
2) Critical view technique
3) Infundibular technique-> widely used
4) Dissection of main bile duct with visualization of cystic
duct or common duct insertion->
( increased chance of either thermal or retraction
injury to CBD, aberrant insertion of cystic duct can
also complicate this approach)
Routine intra-op cholangiogram (IOC)
Performed routinely or not ?
Done via presumed cystic duct
If this happens to be CBD, injury has already occurred!!
IOC does not identify all aberrant ducts
Arterial anatomy not identified
IOC does not prevent BDI but may reduce its severity ( if
correctly performed & interpreted, IOC can prevent
complete CBD transection)
IOC higher rate of intra-op identification of BDI
decreased cost of treatment & shorter hospital stay
If critical view not obtained due to inflamation or hostile anatomy
perform IOC prior to dividing cystic duct .
Routine IOC reduces CBD injuries from 0.58% to 0.39% (American
Medicare data base study)
Critical view of safety
Calot’s triangle dissected free
of all tissue except cystic duct
Base of liver bed exposed
When this view is achieved,
the two structures entering GB
can only be cystic duct &
Not necessary to see CBD
(A)Usual anatomy when infundibular technique applied. Cyst duct-gallbladder
junction is characterized by a flaring tunnel shape(boldlines). Arrow represents
circumferential dissection of CD-gallbladder junction during infundibular
(B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel
shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries.
CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary
injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg
Cystic duct or CBD?
2 – 3mm wide 5mm wide CD > 5mm – Is it
Even with low
duodenum must be
duct very rare
-- 2 ducts seem to go
Gallbladder – one
must be CBD
No vessels on Vessels on --
Classical LC BDI
Type A Cystic duct leaks or leaks from
small ducts in liver bed
Type B Occlusion of aberrant right
Type C Transection of aberrant right
Type D Partial (<50%) transection of
major bile duct
Type E Transection involve >50%
Subdivided as per Bismuth
classification into E1 to E5
Strasburg Classification, cont’d
E: injury to main duct (Bismuth)
E1: Transection >2cm from
E2: Transection <2cm from
E3: Transection in hilum
E4: Seperation of major ducts in
E5: Type C plus injury in hilum
Class I CBD mistaken for cystic duct, but error recognized before CBD is divided.
Class II Damage to CHD from clips or cautery placed on duct. Often occurs
where visibility is limited due to inflammation or bleeding.
Class III Most common (60%), CBD mistaken for cystic duct. Common duct is
transected and variable portion that includes junction of cystic and common duct
is excised .
Class IV Damage to right hepatic duct , either because this structure is mistaken
for cystic duct, or injured during dissection.
Bile duct injury
Prevention should be main point
(much more important than treatment)
ALL laparoscopic cholecystectomies ARE difficult!
None of them is easy!
If injury occurred, …
who should treat it?
when should it be treated?
how should it be treated?
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
Intraoperative laparoscopic ultrasound (IOUS) .
Mastery of Surgery 6th ed.
Changing the Culture of Cholecystectomy:
Safety and avoiding BDI should be paramount concern to
surgeon performing LC.
LC can be converted to open procedure or even aborted if
local conditions present unacceptable risks of danger.
As Strasberg points out, the negative effects of conversion
or even aborting procedure and placing a cholecystostomy
tube are minor compared with the negative effect of a BDI.
Failure of progression of dissection, inability to grasp and
retract gallbladder, anatomic ambiguity, poor visualization
of field due to hemorrhage, should trigger the surgeon to
consider alternate approach.
Conversion rate < 5% can be expected in hands of a well
trained laparoscopic surgeon.
Timing of Identification
• Unexpected ductal structures seen
• Bile leak into field from lacerated or transected
• Depends on continuity of bile duct &
• Presence or absence of bile leak
Presentation of Bile Duct Injuries
About 25% recognized intraoperatively.
About 25% discovered within 24 hours post- operative
About 50% present weeks to years post-operative.
Most BDI are not recognized intraoperatively, and patients sent home after or
within 24 hours.
Patients who fails to recover within first few days or develop progressive vague
Abdominal fullness, distension, nausea, vomiting, abdominal pain, fever and chills.
Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis, or multi organ
Biliary obstructions-> anorexia, jaundice, liver enzyme elevation
Both can occur simultaneously
Concomitant vascular injuries (complicate matter)
Obstruction secondary to biliary stricture appear weeks to month later and may
present with recurrent colangitis, obstructive jaundice, or secondary biliary
If experienced, convert to Open Procedure and perform
Cholangiography (determine extent of injury)
If not experienced, perform cholangiogram laparoscopically with
intent of referring patient (placement of drains)
Consult an experienced hepatobiliary surgeon
Quicker the repair, better the outcome!!!
Biliary catheter for decompression of biliary tract and
control of bile leaks
Percutaneous drainage of intraperitoneal bile collection
Clinical Presentation (post-op)
• Clip ligation or resection of CBD obstructive
• Bile Leak
• Bile from intra-op drain or
• More commonly, localized biloma or free bile
ascites / peritonitis, if no drain
• Diffuse abdominal pain & persistent ileus
several days post-op high index of suspicion
possible unrecognized BDI
Post-Operative Detection Plan
Controlling sepsis, establish biliary drainage, postulate
diagnosis, type and extent of bile duct injury.
No need for an urgent laparotomy. Biliary reconstruction in
presence of peritonitis results a statistically worse outcome.
No need for urgent with reconstruction of biliary tree.
Inflammation, scar formation and development of fibrosis
take several weeks to subside.
Reconstruction of biliary tract is best performed electively
after interval of at least 6 to 8 weeks.
Ultrasonagraphy and CT -- Ductal dilatation
intra-abdominal collection and dilatation of
ERCP—biliary anatomy and assess
PTC—define biliary anatomy
proximal to injury
MRCP—noninvasive (can miss
HIDA scan -- If doubt exists, HIDA scan can
confirm leak but not the specific leak site
MR angiography—vascular injuries
When realise that there is an injury, ASK for HELP!
If possible do not try to repair, even you are experienced
An experienced and FRESH surgeon should repair the injury.
If it is impossible AND it is a difficult injury that you can not treat,
place catheters and refer the patient.
There is no ‘Tissue Lost’, primary repair (end to end CBD repair)
stricture rate is high!!!
There is ‘Tissue Lost’, biliodigestive anastomosis:
Primary repair high incidence of failure
percutaneous or endoscopic balloon dilatation later
Preoperative Investigation and Preparation for the
■ Communication with previous surgeon
■ Previous surgical report
■ Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST,
albumin, coagulation parameters, white blood cell count
Principles of Repair
■ Anastomosis should be tension free, with good blood supply,
mucosa to mucosa and of adequate caliber.
■ Hepaticojejunostomy should be used in preference to either
choledochocholedocotomy or choledochoduodenostomy.
■ Anterior longitudinal opening in the bile duct with a long side-to-
side anastomosis is preferred.
■ Dissection behind the ducts should be minimized in order to
minimize devascularization of the duct.
Timing of Repair
Factors favoring immediate repair are:
(1) Early referral
(2) Lack of right upper quadrant
(3) Simple injuries
(4) No vascular injury and
(5) Stable patient
Factors favoring delayed repair are:
(1) Late (less than 1week after injury) referral
(2) Complex injuries (types E4, E5)
(3) Thermal etiology
(4) Concomitant ischemic injury
Type B & C
Potentialy serious injuries
More common since introduction
Asymptomatic atrophy of
hypertrophy of normally
Pain or cholangitis
many yrs. after injury
silent Type B
<25% 25% - 50% or
Caused by diathermy or
Small bile duct
Type E (>50%)
B,C and E1 to E5 are major
ERCP – multiple stents
• Lateral duct wall injury or
cystic duct leak
controls leak & provides
• Distal CBD must be intact
to augment internal
drainage with endoscopic
Simple injuries types A and D may be treated in community
setting when discovered intraoperatively by endoscopic or percutaneous
techniques when they present in postoperative period.
Complex injuries that require hepaticojejunostomy for repair (types B and C
injuries and most to type E injuries).
More complex injuries types E1 and E2 may also be treated by nonsurgical
techniques when they present as strictures.
Notations >2 cm and <2 cm in types E1 and E2 indicate length of common
hepatic duct remaining.
Immediate intra operative diagnosis Delayed diagnosis
injurMinor y Major injury
Clip open duct
Transfer to tertiary centre
Call second surgeon
Low -output High-output
Resolve < 5-7 days Continued
Duct of Luschka
Cystic duct stump leak
Suspected CBD injury
PTC to deliniate anatomy
Repair by experienced
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
ERCP – clips across CBD
normal-sized distal CBD
upto site of transection
Biliary enteric anastomosis
Most laparoscopic BDI –
of biliary tree
nonischemic bile duct
Reestablishment of bile flow into proximal GIT
In a manner that prevents cholangitis, sludge
or stone formation, restricturing & progressive
Bile duct intact & simply narrowed percutaneous
or endoscopic dilatation
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 over a 5-F pediatric feeding tube
to serve as a biliary stent
• Multidisciplinary management of BDI expertise of
surgeons, radiologists & gastroenterologists
• Mismanagement lifelong disability & chronic liver
• BDI with lap. Chole results of operative repair,
excellent in Specialist Centres
• Choledochal cysts are focal or diffuse dilatations of
the biliary tree
• Most commonly present in childhood but
increasingly being recognized in adults.
• represent significant clinical challenges where
proper evaluation and management are paramount
to prevent serious clinical sequelae.
• incidence of choledochal cysts varies significantly
throughout the world.
• In Asia, incidence is as high as 1 in 1000 population
with 50% cases representing from Japan
• In Western Countries, choledochal cysts occur less
frequently with reported cases ranging from 1:13,000
to 1:150,000 population.
• Occur more commonly in females with a M:F
ratio of 1:3-4
• Classically present in childhood, but recent series
report as many as 25% of cases presenting in
• Proper management of choledochal cysts requires consideratio
of their classification.
• Original Classification by Alonso-Lej and associates exclusively
involved the extrahepatic duct
• The classification was revised by Dr. Todani and colleagues in
1977 to include intrahepatic cystic anomalies
• Type I (50-85%): They are characterized by cystic or
fusiform dilation of the common bile duct.
• Type IA is defined by cystic dilation of the entire
extrahepatic biliary tree,
• Type IB is defined by focal, segmental (often distal)
dilation of the extrahepatic bile duct.
• Type IC is defined by smooth, fusiform (as opposed to
cystic) dilation of the entire extrahepatic bile duct.
• Type II ( 2%): true diverticula of the extrahepatic bile duct
and communicate with the bile duct through a narrow
• Type III ( 5%) : Cystic dilatation of the intraduodenal portion
of the extra hepatic common bile duct; also known as a
• Type IV (30-40%): Involve multiple cysts of the intrahepatic
and extrahepatic biliary tree; IV A > IV B
• Type V: Caroli’s Disease
• Type 1 A
Type IV A
Type IV B
• Cause not currently known. Most cysts are congenital in
• It is unclear whether cases of choledochal cysts diagnosed
in adults are acquired or late manifestations of congenital
• There may be multiple mechanisms involved in the
creation of biliary cysts
• The high incidence of biliary cysts in Asia suggests a role for
either genetic or environmental factors.
• Congenital weakness in the bile duct wall
• Abnormal biliary epithelial proliferation before bile duct
cannulation is complete
• Bile duct obstruction or distension in the prenatal or
• Fetal viral infection
• Pancreaticobiliary maljunction
APBJ – Babbit Theory
• Pancreaticobiliary maljunction is defined as an
extramural junction of the pancreatic and biliary ducts in
the duodenum beyond the intramural sphincter function
• characterized by a long common channel (typically over 2
• Increased reflux of pancreatic juice into the biliary tree --
• Biliary atresia , Duodenal atresia, Colonic atresia,
• Pancreatic arteriovenous malformation, Heterotopic
• Multiseptate gallbladder
• OMENS plus syndrome
• Ventricular septal defect, Aortic hypoplasia,
• Congenital absence of the portal vein
• Familial adenomatous polyposis
• Autosomal recessive and autosomal dominant
polycystic kidney disease
• Classic triad : pain, jaundice, and abdominal mass. ( ~ 10%)
• Infants commonly present with elevated conjugated
bilirubin (80%), failure to thrive, or an abdominal mass
• In patients older than 2 years of age, abdominal pain is the
most common presenting symptom.
• Intermittent jaundice and recurrent cholangitis are also
common, especially in patients with a type III cyst.
• U/S abdomen : to detect the presence
• CT scan – more appropriate in adults.
• Cholangiography: gold standard , PTC or ERC in adults
and intraoperative cholangiography in small children
• Liver function tests
• Type I: excision of the cyst with its mucosa and
reconstruction by Roux-en-Y hepatico-jejunostomy
• Type II: excision of the diverticulum and suturing of
the CBD wall
• Type III: endoscopic sphincterotomy is done.
• Type IV: Extrahepatic biliary resection,
cholecystectomy, and biliary reconstruction
• Type V: Liver transplantation, hepatectomy