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Bile duct injury during laparoscopic cholecystectomy
Bile Duct Injuries
Prevention & Management
Dr.S.Easwaramoorthy
MS FRCS(Eng) FRCS (Glas) FRCS (Edin)
Head of Dept of Minimal Access Surgery
Lotus hospital, Erode
Examiner, RCS of Edinburgh
Executive Member, South Zone IAGES
World’s First Lap Chole
Phillipe Mouret-1987
Erich Muhe-
1985
They made it feasible, let us make is safe!....
Risk of Bile Duct Injury
•More Often
•Happens in 0.5% cases
•Major injury
•More proximal ducts
1.6 million Lap chole in Medicare beneficiaries-1992-1999
Lap Chole is the answer,
but…
Learning Curve Vs Real Danger
Why more BDI?
Upward retraction of fundus
So What?
1. Upward retraction of fundus
2. Down and out retraction of Hartmann’s
Assistant’s Left hand in Open Chole
Surgeon’s Left hand in Lap chole
Visual Perceptual Illusion
You see What U want to See
Pathogenesis of Bile Duct Injury I
Misidentification of Bile duct as cystic duct
Classical BDI during Lap Chole
Disaster
Dangerous Anatomy
Dangerous Pathology
Bile duct is cut twice to remove the GB
Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury
Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury
Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury
Bile duct injury during laparoscopic cholecystectomy
1.Trouble Prevention I
1. Follow the Steps of Safe Cholecystectomy
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View
1. Look for Cues of bile duct injury
2. Cholangiogram
1.Identify Junction of Cystic duct and GB
Infundubular Technique
Elephant Trunk Sign
99% Cholecystectomy is better than
101% cholecystectomy!
Beware: Hidden cystic duct syndrome
2.Rouviere’s Sulcus
Extra biliary reference point for safe navigation!
Are we One Hundred Percent Sure?!
3.Strasburg’s Critical View of Safety
Trouble Prevention II
1. Steps to avoid bile duct injury
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View of Safety
1. Look for Cues of bile duct injury
Red Flag Signs of BDI
• Unclear Anatomy/Anomaly
• Dangerous pathology
– Acute Cholecystitis
– Mirrizi’s Syndrome
– Impacted stone at Cystic duct
– Large stone in Hartmann’s pouch
• Clips are small for the duct!
• Unexplained bile leak!!
• Unusual field of vision
– More Duodenum, Less Liver
Golden
yellow
Trouble Prevention III
1. Steps to avoid bile duct injury
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View
1. Look for Cues of bile duct injury
2. Cholangiogram
When in doubt,
Consider Cholangiogram
Indication
Unclear Anatomy
Suspected Bile duct stone
May not prevent BDI but could aid its early recognition!
Bile duct injury during laparoscopic cholecystectomy
2.Trouble Management
• How to recognize BDI?
• What Investigations?
• When to intervene?
• Which repair?
Classical BDI during Lap Chole
1.How to recognize BDI
• Intra operatively(25%)
– Don’t panic!
– Drain/Control of sepsis
– Refer
• Post operatively
– Pain
– Bile leak
• Pain, Bile in the drain, signs of peritonism
– Biliary Obstruction
• Abnormal LFT, Jaundice, cholangitis
2.Role of Imaging in BDI
1. US/CT abdomen
– To look for any collection/ Guided drainage
1. HIDA scan
– Confirms leak but fail to give anatomic detail we need
1. PTC
– To visualize the proximal ducts and assess the grade the injury
– Stenting?
1. MRCP
– Non invasive Test of Choice to assess the grade of injury
– Both proximal and distal ducts could be seen and leaks also could
be identified
1. ERCP
– Mainly delineate distal ducts only
– Mainly for Therapeutic purpose /operator dependent
3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic
ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
US/CT Guided Drainage
ERCP and Stenting
A D
Bilioma is prone for infection and bile can destroy
tissues, so act quick!
MRCP & then ERCP
ERCP/Sphincterotomy/Stenting
3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic
ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
B Rare
3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
C
Rare
Types of Major Bile Duct Injuries
Typ
e E
Bismuth Classification of Bile Duct Stricture
1 Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm
2 Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm
3 Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved
4 Hilar stricture, with involvement of confluence and loss of communication between right and left
hepatic duct
5 Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the
common hepatic duct
E 1 & 2 E3 E5E4
MRCP & ERCP in BDI
35 yr lady with classical post lap chole
MRCP can see both above and below
the level of biliary obstruction
So no need for PTC! Excision injury of bile duct
4.Which repair & When?
• Hepaticojejunostomy
– Let us leave it to the experts…
– 1st
time is the best
– <72 hr or wait till 6 weeks
• End to end repair over T tube: seldom done
Bile duct injuries associated with Lap chole.
Timing of repair and long term outcome
Arch Surgery 2010 : 145 (8): 757-763
Hepatico jejunostomy-1
Hepatico jejunostomy-2
Tension-free and widely patent,
with a mucosa-to-mucosa anastomosis.
Ensure well-vascularized bile ducts and
use monofilament absorbable sutures
Conclusion
• Let us adhere to safety rules of Lap chole
• Bile duct injuries are disastrous
• Management of BDI needs Specialist
Bile duct injury during laparoscopic cholecystectomy

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Bile duct injury during laparoscopic cholecystectomy

  • 2. Bile Duct Injuries Prevention & Management Dr.S.Easwaramoorthy MS FRCS(Eng) FRCS (Glas) FRCS (Edin) Head of Dept of Minimal Access Surgery Lotus hospital, Erode Examiner, RCS of Edinburgh Executive Member, South Zone IAGES
  • 3. World’s First Lap Chole Phillipe Mouret-1987 Erich Muhe- 1985 They made it feasible, let us make is safe!....
  • 4. Risk of Bile Duct Injury •More Often •Happens in 0.5% cases •Major injury •More proximal ducts 1.6 million Lap chole in Medicare beneficiaries-1992-1999 Lap Chole is the answer, but… Learning Curve Vs Real Danger
  • 5. Why more BDI? Upward retraction of fundus
  • 6. So What? 1. Upward retraction of fundus 2. Down and out retraction of Hartmann’s Assistant’s Left hand in Open Chole Surgeon’s Left hand in Lap chole
  • 7. Visual Perceptual Illusion You see What U want to See
  • 8. Pathogenesis of Bile Duct Injury I Misidentification of Bile duct as cystic duct Classical BDI during Lap Chole Disaster Dangerous Anatomy Dangerous Pathology Bile duct is cut twice to remove the GB
  • 9. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury
  • 10. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury
  • 11. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury
  • 13. 1.Trouble Prevention I 1. Follow the Steps of Safe Cholecystectomy – Identify GB-Cystic duct junction • Elephant Trunk sign – Rouviere’s Sulcus – Critical View 1. Look for Cues of bile duct injury 2. Cholangiogram
  • 14. 1.Identify Junction of Cystic duct and GB Infundubular Technique Elephant Trunk Sign 99% Cholecystectomy is better than 101% cholecystectomy! Beware: Hidden cystic duct syndrome
  • 15. 2.Rouviere’s Sulcus Extra biliary reference point for safe navigation!
  • 16. Are we One Hundred Percent Sure?! 3.Strasburg’s Critical View of Safety
  • 17. Trouble Prevention II 1. Steps to avoid bile duct injury – Identify GB-Cystic duct junction • Elephant Trunk sign – Rouviere’s Sulcus – Critical View of Safety 1. Look for Cues of bile duct injury
  • 18. Red Flag Signs of BDI • Unclear Anatomy/Anomaly • Dangerous pathology – Acute Cholecystitis – Mirrizi’s Syndrome – Impacted stone at Cystic duct – Large stone in Hartmann’s pouch • Clips are small for the duct! • Unexplained bile leak!! • Unusual field of vision – More Duodenum, Less Liver Golden yellow
  • 19. Trouble Prevention III 1. Steps to avoid bile duct injury – Identify GB-Cystic duct junction • Elephant Trunk sign – Rouviere’s Sulcus – Critical View 1. Look for Cues of bile duct injury 2. Cholangiogram
  • 20. When in doubt, Consider Cholangiogram Indication Unclear Anatomy Suspected Bile duct stone May not prevent BDI but could aid its early recognition!
  • 22. 2.Trouble Management • How to recognize BDI? • What Investigations? • When to intervene? • Which repair? Classical BDI during Lap Chole
  • 23. 1.How to recognize BDI • Intra operatively(25%) – Don’t panic! – Drain/Control of sepsis – Refer • Post operatively – Pain – Bile leak • Pain, Bile in the drain, signs of peritonism – Biliary Obstruction • Abnormal LFT, Jaundice, cholangitis
  • 24. 2.Role of Imaging in BDI 1. US/CT abdomen – To look for any collection/ Guided drainage 1. HIDA scan – Confirms leak but fail to give anatomic detail we need 1. PTC – To visualize the proximal ducts and assess the grade the injury – Stenting? 1. MRCP – Non invasive Test of Choice to assess the grade of injury – Both proximal and distal ducts could be seen and leaks also could be identified 1. ERCP – Mainly delineate distal ducts only – Mainly for Therapeutic purpose /operator dependent
  • 25. 3.Trouble Management Type Strasburg Classification of BDI A Cystic duct leaks or leaks from small ducts in the liver bed B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts C Transection without ligation of the aberrant right hepatic duct D Lateral injuries to major bile ducts E Subdivided as per Bismuth’s classification into E1 to E5 US/CT Guided Drainage ERCP and Stenting A D Bilioma is prone for infection and bile can destroy tissues, so act quick!
  • 26. MRCP & then ERCP ERCP/Sphincterotomy/Stenting
  • 27. 3.Trouble Management Type Strasburg Classification of BDI A Cystic duct leaks or leaks from small ducts in the liver bed B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts C Transection without ligation of the aberrant right hepatic duct D Lateral injuries to major bile ducts E Subdivided as per Bismuth’s classification into E1 to E5 B Rare
  • 28. 3.Trouble Management Type Strasburg Classification of BDI A Cystic duct leaks or leaks from small ducts in the liver bed B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts C Transection without ligation of the aberrant right hepatic duct D Lateral injuries to major bile ducts E Subdivided as per Bismuth’s classification into E1 to E5 C Rare
  • 29. Types of Major Bile Duct Injuries Typ e E Bismuth Classification of Bile Duct Stricture 1 Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm 2 Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm 3 Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved 4 Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct 5 Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct E 1 & 2 E3 E5E4
  • 30. MRCP & ERCP in BDI 35 yr lady with classical post lap chole MRCP can see both above and below the level of biliary obstruction So no need for PTC! Excision injury of bile duct
  • 31. 4.Which repair & When? • Hepaticojejunostomy – Let us leave it to the experts… – 1st time is the best – <72 hr or wait till 6 weeks • End to end repair over T tube: seldom done Bile duct injuries associated with Lap chole. Timing of repair and long term outcome Arch Surgery 2010 : 145 (8): 757-763
  • 33. Hepatico jejunostomy-2 Tension-free and widely patent, with a mucosa-to-mucosa anastomosis. Ensure well-vascularized bile ducts and use monofilament absorbable sutures
  • 34. Conclusion • Let us adhere to safety rules of Lap chole • Bile duct injuries are disastrous • Management of BDI needs Specialist