Bile duct injuries BDI

1. BILE DUCT INJURIES
DURING
CHOLECYSTECTOMY
Anup shrestha
CMC

2. Development of Biliary System
• 4th week of development , a projection appears in the ventral
wall of the primitive midgut at the level of the primitive
duodenum

3. Anatomy of Biliary System
• The CBD is formed by the union of the cystic and CHDs. The
CBD is approximately 8 cm in length.
• The normal diameter of the CBD ranges from 4 to 9 mm.
• The CBD is considered enlarged if the duct diameter exceeds
10 mm.
• The CBD is divided into 4 parts
• The supraduodenal portion
• The retroduodenal portion
• The intrapancreatic portion
• The intraduodenal portion

5. Anomalies Hepatic Ducts

6. CBD
(1) a single duct opening into the pylorus or antrum
(2)a single duct opening into the gastric fundus
(3) a single duct entering the duodenum independently
of the pancreatic duct
(4) two separate ducts entering the duodenum;
(5) a bifurcating duct, with one branch entering the
duodenum and the other branch entering the Stomach
(6) a bifurcating duct with both branches entering the
duodenum;
(7) a septate CBD, with two openings of the single duct
into the duodenum.

7. Cystic Duct
(A) Long cystic duct with
low fusion with common
hepatic duct.
(B) Abnormally high
fusion of cystic duct with
common hepatic duct
(trifurcation).
(C) Accessory hepatic
duct.
(D) Cystic duct entering
right hepatic duct.
(E) Cholecystohepatic
duct.

8. EPIDEMIOLOGY OF BILE DUCT
INJURIES
• The incidence of major bile duct injury during laparoscopic
cholecystectomy is 0.3% to 0.5%, while it is 0.1% to 0.2%
with open cholecystectomy.
• The introduction of new techniques such as single-port
laparoscopic cholecystectomy and robotic cholecystectomy
do raise some concerns that injuries could become more
common.
• Lap converted to open cholecystectomy also increases the
risk of BDI due to less training
(Kaman et al, 2006; Nuzzo et al, 2005; Pekolj et al, 2013;
Tantia et al, 2008; Waage & Nilsson, 2006)..

9. Mechanism of BDI (Factors)
• Misidentification of Structures
- When you think it’s a cystic duct but it is
CBD or CHD or RHD or Aberrant HD
• Absence of safety measures
* Carelessness
• Technical error
• use of an end-viewing laparoscope, which alters the surgeon’s
perspective of the operative field.
• Excessive cephalad retraction of the gallbladder fundus can cause the
cystic duct and common bile duct to become aligned in the same plane.
• Human Error
- injuries were caused by visual-perceptual illusion or inadequate
visualization
• - failure to define the “critical view of safety,”
• excessive use of cautery resulting in thermal injury, application of multiple
clips for bleeding in the Calot’s triangle, deep dissection into GB bed or
ischemia of CBD secondary to extensive circumferential dissection

11. Critical View of Safety

12. Pathologic Factors
•Acute cholecystitis
•cholangitis,
•gallstone pancreatitis
(Kholdebarin et al, 2008)
increased
incidence of bile
duct injuries
(1.7%)

13. Prevention
• Bile Duct “Time Out”
(Be. S.A.F.E.)
• Be—Bile duct
• S—Sulcus of Rouvier
• A—Artery (hepatic
artery)
• F—Fissure (umbilical
fissure)
• E—Environment (back
the camera out for
improved Perspective,
Ergonomics trocar
setup.

14. Classification

15. Stewart-Way classification

16. Clinical Presentation Of Patients
With Bile Duct Injuries
• only about 10% of injuries are suspected after the first week,
but nearly 70% are diagnosed within the first 6 months after
operation
• Patients with significant bile leaks (types A, C, and D) generally
present within the first week after operation
• Most patients have abdominal pain coupled with fever or other
signs of sepsis or bile leakage from an incision.
• Elevated alkaline phosphatase levels are characteristic
• Major injuries to the common duct (type E injuries) are more
likely to be discovered intraoperatively
• these injuries are diagnosed more often within the first few
postoperative weeks, although patients with a slowly evolving
stricture may not come to attention for several months

17. Clinical manifestation
• Most patients present with jaundice, often coupled with
pain and occasionally sepsis.
• Patients with the stricture may evolve slowly or cause only
partial obstruction.
• Presents with nonspecific complaints, pruritus, or
derangements in liver function tests (LFTs)
• Abdominal distension and pain bile peritonitis
• Focal tenderness localized collection or abscess.
• Hepatomegaly long-standing biliary obstruction.

18. Pathogenic consequences
Fibrosis
• high local concentrations of bile salts fibrogenesis
• deposition of collagen and extracellular matrix
proteins fibrosis and scarring around bile ducts and
ductules.

19. Atrophy
• portal venous obstruction or bile duct occlusion
• Compensatory contralateral hypertrophy are
frequently found in benign strictures.
• the dilated ducts within the atrophic segments
often are filled with infected bile and debris
• associated with significantly longer reconstructive
operations,higher intraoperative blood loss, and
greater blood transfusion requirements

20. Portal HTN
• 15% to 20% of patients with benign biliary stricture have
concomitant portal hypertension
• Result of secondary hepatic fibrosis or direct damage to
the portal vein
• Outcome of patients with biliary strictures and portal
hypertension is much worse than for patients without
portal hypertension, with an in-hospital mortality rate of
25% to 40%
(Blumgart & Kelley, 1984; Chapman et al, 1995)

21. Management
• Surgeon must define the type and extent of
injury
• Is there any life-threatening coexisting
conditions such as sepsis, cholangitis,
ongoing biliary leakage, and abscess?
• Are there associated vascular injuries?
• Is there evidence of lobar atrophy?

22. Investigation :
Radiological Imaging
• Duplex ultrasonography: Is an excellent,
noninvasive means of showing intrahepatic
ductal dilation and may reveal a subhepatic
fluid collection or evidence of vascular
damage.
• Disadvantage : it is of little value in
assessing the extent of a stricture and is of
no value if the biliary tree is decompressed.

23. Percutaneous transhepatic
cholangiography(PTC)
• Helps to outline all branches of
the right and left intrahepatic
biliary tree, particularly in cases of
high bile duct stricture and
recurrent stricture after previous
reconstruction
• Drainage catheters should be left
in place following PTC if a
complex injury is identified on
cholangiogram because palpation
of the catheter intraoperatively
can help guide identification of
ductal structures during definitive
repair
PTC

24. MRCP
•Provides accurate images of the biliary
tree and yields anatomic information.
•Intravenous (iv) contrast agents is
found to detect the site of leak with
80% accuracy
• Ratcliffe and colleagues (2014)

25. HIDA
• Isotopic scanning
techniques may be
valuable in assessing bile
duct strictures, particularly
the functional assessment
of incomplete strictures
• Establish the presence of
a persistent bile leak
• It offers a dynamic and
quantitative assessment of
liver function and of the
clearance of bile across
anastomoses and
stenoses

26. Preoperative Preparation
• We begin antibiotics immediately before operation and
continue appropriate treatment for 5 to 7 days
postoperatively if cholangitis is a preoperative feature.
• prolongation of the prothrombin time, should be treated
with vitamin K or fresh frozen plasma
• complications of biliary injuries must be addressed before
biliary reconstruction

27. Surgical Treatment :Injury Recognized At
Initial Operation
• Immediate open conversion and repair by an experienced
surgeon is associated with reduced morbidity, shorter
duration of illness, and lower cost
• Injuries involving the biliary confluence, in which failure of
the initial repair and loss of bile duct length may result in
isolation of the right and left hepatic ducts; repair
becomes more difficult
• Principle : (1) maintenance of ductal length below the
hilus without sacrifice of tissue and (2) avoidance of
uncontrolled postoperative bile leakage.

28. Types of injury
• complete duct transection : end-to-end repair.
- if the transected ends can be apposed
without tension
-anastomosis is created using a single
layer of interrupted absorbable sutures
- avoided due to complications like
stricture and leaks

29. Surgical Treatment : continue
Injury to the lateral duct wall: direct suture repair
• Extensive dissection risks further injury and late stricture
formation
primary choledochorrhaphy: 1.vein patches
2. cystic duct stump
3. pedicled flaps of jejunum
Roux-en-Y loop of jejunum with t tube: advantage
1. bile duct length is maintained.
2. the jejunal serosa is used to cover the defect,
secured in place with fine, interrupted absorbable
sutures to the bile duct wall without attempting direct
• approaches to the ragged edge of the damaged duct

30. INJURY RECOGNIZED IN THE
IMMEDIATE POSTOPERATIVE PERIOD.
• If external biliary fistula  avoid early reoperation.
• Carry out appropriate investigations keep the patient well
nourished and free of infection.
• If fistulography  reveal continuity between the biliary
system and the GI tract, a prolonged period of drainage is
warranted and may result in spontaneous closure.
• More severe lacerations or complete transections of the
common duct or an aberrant right sectoral hepatic duct with
ongoing bile leakage  the proximal ducts are small in
caliber  Immediate surgical treatment is difficult.

31. Injury Recognized In The Immediate
Postoperative Period. (Cont..)
• delayed approach  If fluid losses from the biliary fistula
remain high endoscopic or percutaneous stent across the
defect may reduce output from the fistula, hasten
closure(Lalezari et al, 2013; Weber A., et al, 2009)

32. Injury Presenting At An Interval After Initial
Operation.
• The principles of the surgical management of late bile
duct strictures
(1) exposure of healthy proximal bile ducts draining all
areas of the liver
(2) preparation of a suitable segment of distal mucosa for
anastomosis
(3) creation of a mucosa-to-mucosa sutured anastomosis
of the bile ducts to the distal conduit, Roux-en-Y loop of
jejunum.

33. Technical Approaches to Biliary Repair
• END-TO-END DUCT REPAIR: earliest techniques used
for reconstruction
feasible if injured segment is 1-2 cm and the 2 ends can
be opposed without tension
Kocher maneuver allows tension-free anastomosis
associated with a 50% to 60% incidence of long-term
failure

34. BILIARY-ENTERIC REPAIR
 PRO:
- normal physiology → less ulcers and malabsorbtion
- only one anastomosis: easier and faster to perform
- post-operatory control through endoscope
- no secondary biliary cirrhosis reported
Moraca, Arch Surg 2002
Sicklick, Ann Surg 2005
HEPATICO-DUODENOSTOMY:
 CONTRA:
- difficult to perform for proximal bile duct lesions
(75% of lesions)
- need to an experienced surgeon
- risk of cholangitis

35. ROUX HEPATICOJEJUNOSTOMY:
(most performed anastomosis)
- preferable choice in lesions between the hepatic duct
and the lobar ducts (less tension of the anastomosis)
- lower number of strictures
Sicklick, Ann Surg 2005
McPartland, Surg Clin N Am 2008

36. CHALLENGES
• When the stricture is below the confluence (Bismuth type
1 or 2), a direct anastomosis to the hepatic duct stump is
usually straightforward. By contrast, when the stricture
encroaches on the confluence of the right and left hepatic
ducts (type 3) or extends proximally so as to isolate the
ducts (type 4), the problem becomes more complex
• Attempts to identify the duct below the stricture are
unnecessary because the distal duct generally cannot be
used for anastomosis;

37. Combined modality approaches
• when the risk of recurrent stricture
or stone formation is believed to
be high, hepaticojejunostomy may
be performed over a transjejunal
tube brought to the exterior across
the blind end of the Roux limb.
The defunctionalized Roux limb is
deliberately left long, and the end
is secured subcutaneously or
subperitoneally, this allows easy
subsequent access for
cholangiography, cholangioscopy,
dilation, or stone removal

38. •Liver Resection
• Remains an important option in the treatment of refractory
benign bilary stricture or complex injury with vascular
involvement
•Liver Transplantation
• Usually done because of a devastating combined
vascular and biliary injury

39. OPERATIVE MORBIDITYAND
MORTALITY
• Intraabdominal abscess
• wound infection
• Cholangitis
• sepsis
• biliary fistula
• postoperative hemorrhage
• Pneumonia
• The perioperative mortality rate in many series ranged
from 5% to 8%

40. LONG-TERM RESULTS AND FOLLOW-
UP.
• Pitt and colleagues (1982) reported that two thirds of
recurrent strictures were apparent within 2 years
• Tocchi and colleagues (1996) observed that 40% of
restrictures were identified more than 5 years after the initial
operation
• Tornqvist and colleagues (2009) analyzed more than 374,000
laparoscopic cholecystectomies over 40 years time in
Sweden and identified 1386 injuries requiring reconstructive
surgery; reported that injured patients had a fourfold increase
in the risk of death from liver disease and a signficantly
decreased overall survival.
• In 2018, Booij KAC et al reported BDI related mortality was
3.5% in 800 BDI patients

41. NONOPERATIVE APPROACHES
• percutaneous balloon dilation
• limited in its application to patients in whom biliary
continuity is intact or has been restored by a previous
attempt , at repair; it has no role for strictures at or above
the confluence and cannot be used if the bile duct has
been transected
• complications related to balloon dilation or to the
percutaneous catheter are frequent and include
hemobilia, bile leak, and cholangitis in 20% of patients.

42. Endoscopic
stenting
• multiple plastic or
metallic stents are
placed across the
stricture
endoscopically
Chandrasekar T S, Hussain H, Murugesh M. Endoscopic management of biliary
injuries and leaks. J Dig Endosc 2012;3, Suppl S1:27-32

44. Thank You