Bile duct injuries.. french connection

1. CPC
Dr Gul Rehman Khan
Resident Surgical Unit 2

2. Patient Profile
• Name - xyz
• Age- 52 years
• Sex- female
• From - Jehlum
• Admitted - 24 April
• Via - OPD

3. Presenting Features
• Known case of Diabetes Mellitus
Presented with:
• Pain RHC
• Nausea and vomiting
• Generalized itching
• Generalized weakness - 1 month

4. Hx of Present Illness
• Hx of nausea with off and on vomiting
• Anorexia and generalized weakness
• Itching all over the body
• Clay colored stools and dark colored urine
• She noticed yellow discoloration of sclerae

5. Past History
• Underwent laparoscopic cholecystectomy in
peripheral hospital
• Had a bile duct injury
• Laparatomy was done and drain was placed
• Drain was removed later when bile flow
ceased
• Presented to FFH Rawalpindi 6 weeks after
laparatomy

6. Examination
• 52 years old lady lying on bed
• Anxious looking
• Well oriented in time, place and person
• BP = 130/80
• Pulse= 90 /min
• Temp= Afebrile
• R/R= 19/min

7. Examination
• Deeply jaundiced and emaciated.
• No other general physical abnormalities
detected.

8. Abdominal Examination
• Mild tenderness in RHC
• Rest of abdomen soft and non-tender
• Rest of systemic examination was
unremarkable

9. Lab Investigations
Blood CP :
◦ Hb = 8.6 g/dl ,
◦ WBCs = 16.21 x 109/L
◦ Platelets= 442,000/ mm3 109 /l
RFTs =
◦ Urea: 18.4 mmol/L
◦ Creat: 314 mmol/L
LFTs =
◦ Bilirubin: 55 umol/L
ALP 1067 U/L
BSR = 252 mg/dl
Serum Albumin: 2.4 g/dl
Coagulation profile: deranged

10. Imaging Studies
• USG-- Dilated intrahepatic biliary channels
CBD obscured
• ERCP—only distal duct (infra duodenal)could
be opacified. Dye did not go beyond that.
• MRCP—cut off at the confluence of right and
left hepatic duct

11. MRCP

12. DIAGNOSIS
Bile Duct Injury
Strasberg Type E3

13. MANAGEMENT
• Admission
• IV fluids to correct dehydration
• Inj Vit K 10 mg daily
• 03 units of RCC and 08 units of FFPs arranged

14. Operative Management
• Abdomen was opened by midline incision, excising
the previous laparotomy scar
• Findings: Dense adhesions between duodenum,
transverse colon, hepatoduodenal ligament and the
underside of liver.
• Adhesions lysed by sharp dissection:
– To isolate hepatoduodenal ligament from liver and
intestine
– And then to isolate common hepatic artery & left
hepatic artery from other structures

15. • Left hepatic artery was slinged out of the way
• Dissection at porta hepatis to locate the
confluence of left and right ducts
• Hilar plate was lowered to expose the left hepatic
duct
• Left hepatic duct incised and incision extended on
to the stenosed confluence
Operative Management

16. • Right and left ducts flushed with saline using a
Ryle’s tube
• CHD was found to be completely obstructed and
indistinguishable from fibrous tissue enclosing it
• Roux-en-Y hepatico-jejunostomy done using 5/0
Polyglactin sutures, using a parachuting
technique of interrupted sutures
Operative Management

17. Left hepatic artery
slinged

18. Left hepatic
duct opened
between stay
sutures

19. Hepatico-
jejunostomy
Left hepatic
artery

20. Follow Up
• Recovery was uneventful and patient
discharged after 6 days, after removing the
drain
• Stiches removed at 2 weeks.
• Patient gained weight over next 3 months and
has had no complaints

21. Bile Duct Injuries

22. Objectives of this discussion are to:
• Describe etiology of bile duct injuries (BDI) and ways
to prevent iatrogenic injuries
• Describe types of BDI
• Recognition and evaluation of BDI
• Management of BDI

23. Historical Perspective
• First planned cholecystectomy in the world was
performed by Carl Langenbach in 1882.
• First choledochotomy was performed
by Courvoisier in 1890.
• First iatrogenic bile duct injury was described by
Sprengel in 1891.
• Erich Muhe of Boblingen, Germany,
performed the first laparoscopic cholecystectomy in
1985.

24. Etiology of BDI
• Iatrogenic trauma during cholecystectomy is
the leading cause of BDI
• Iatrogenic injury during other surgical
procedures
• Penetrating trauma in accidents

25. BDI During Cholecystectomy
BDI still represents the most serious complication of
LC, with an incidence of 0.3%– 2.7%
(as compared to 0.25 – 0.5 % in open procedure)
___________________________________________
Sherwinter DA, 2018. Medscape

26. Surgeon related factors
• Lack of experience (learning curve in LC)
 Misidentification of biliary anatomy
 Mistaken recognition of anatomical variations of
biliary tree
• Intraoperative bleeding
• Improperly functioning equipment
Factors Increasing Risk of BDI

27. Patient related factors:
• Obscure anatomy during cholecystectomy
 Acute cholecystitis
 Chronic inflammation in the area
 Previous surgery
• Surgical procedure for a malignant tumour
 CA Stomach
 CA gallbladder
 HCC
Factors Increasing Risk of BDI

28. Safe Cholecystectomy Task Force, an initiative of Society of
American Gastrointestinal Endoscopic Surgeons (SAGES)
identifies FIVE factors to ensure safe LC:
1. Establishing Critical View of Safety (CVS)
2. Understanding relevant anatomy (may require IOC)
3. Appropriate retraction / exposure
4. Knowing when to call for help
5. Recognizing the need for an alternate procedure like
subtotal cholecystectomy or conversion to open
procedure
_______________________________________________
Renz BW et al.Bile duct injury after cholecystectomy- surgical therapy.
Visc Med 2017; 33:184-90
Methods of Preventing BDI

29. Cystic Artery (white arrows) and
Junction between cystic duct and artery (black arrow)
Critical view of safety (CVS)

30. Routine Intra-op Cholangiogram (IOC) ?
• 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
• IOC has higher rate of intra-op identification of BDI

31. Infrared Fluorescence Cholangiography
• Still under experimental stage
• Indocyanine Green is given IV, it secretes into bile
and the fluorescence is detected by a special light
source and camera.
• Can be done even in those cases where cystic duct
can’t be cannulated for IOC
• Will cost less and quicker to perform
_________________________________________
FALCON Trial. BMJ. 2016

32. Classification of BDI
 Bismuth – based on distance from confluence
 Strasberg – used most commonly now
 McMahon – relies on circumference of
injured duct
 Stewart -Way: Four classes
 Hannover
 Mattox

33. Strasberg Classification

34. Strasberg Classification

35. Presentation of Bile Duct Injuries
• Manifests as:
 Bile leak due to partial or complete
transection of a bile duct
 Bile duct obstruction - partial or complete
(due to ligation or stricture formation)

36. Evaluation of BDI

37. Clinical Features
Intraoperative Presentation
Identified in index procedure
Delayed Presentation (3 – 7 days after)
 Bile duct obstruction
 anorexia, jaundice, liver enzyme elevation
 Bile leaks
 pain, vomiting, tachcardia, hypotension, ileus
 cholangitis, sepsis, or multi organ dysfunction
 Both can occur simultaneously

38. Late Presentation
• Obstruction secondary to biliary stricture may
appear weeks to months later
• May present with recurrent cholangitis, obstructive
jaundice, or secondary biliary cirrhosis.
Clinical Features

39. Lab Investigations
• LFTs – disproportionate rise of ALP
• CBC – neutrophilia may be found
• Serum albumin – reflects liver function
• Coagulation profile

40. Ultrasound
• Helpful in detecting:
 Fluid collection – localized or generalized
 Dilatation of biliary tree

41. ERCP / MRCP
• Both can identify the site of obstruction or leak.
• MRCP may miss minor leaks
• Minor leaks may be plugged by placing a stent during
ERCP
• ERCP cannot assess proximal extent of obstruction
• MRCP identifies proximal extent of obstruction
• MRA can outline arterial injury

42. Management of BDI

43. Detected in Index Procedure
If surgeon is not expert in biliary injuries:
• Call for help
• Convert to open procedure
• Evaluate injury by IOC / Place a drain
• Reconstruction by primary surgeon results in
success rate of 17 – 30% (90% by experts)
• Consider referral to tertiary care center as it
needs MDT
• Don’t wait for >24 hours for referral

44. If expert surgeon is available:
• Ensure that distal CBD is clear (IOC or
choledochoscopy)
• Minor leak may be repaired by fine (6/0)
monofilament absorbable suture.
• T tube is not necessary
• Post-op endoscopic sphincterotomy helps to
obviate any further leak
Detected Intraoperatively

45. If expert surgeon is available:
• Major injury or complete transection may be
repaired immediately
• Commonly performed procedure is end to
side Roux-en-Y hepaticojejunostomy
Detected Intraoperatively

46. If expert surgeon is available:
• End to end reconstruction of transected duct
can be performed if:
– Edges are healthy and vascularized
– No inflammation or fibrosis
– Anastomosis is tension free
• T tube or Y tube should be used as a stent
• Wide kocherization must be done
Detected Intraoperatively

47. Delayed Detection of BDI

48. Initial Management
• Admission
• IV fluids to correct dehydration
• Broad spectrum antibiotics if sepsis is present
• Inj Vitamin K
• Improve nutritional status

49. Delayed Detection
• Expert endoscopic, radiological and surgical
expertise is needed
• Minor CBD injury (Strasberg Type A, B, C) can
be detected by ERCP and managed by:
– Placing a stent across the leak site, and
– Performing endoscopic sphincterotomy
• A biloma may be managed by USG-guided or
CT-guided drainage

50. • Appropriate timing of surgery is when:
– There is no intra-peritoneal inflammation
– Nutrition status of patient is good
• Usual timing is at least after 6 weeks
• Major injuries (Type D, E1) involve mucosa to
mucosa, tension free, Roux-en-Y
choledochojejunostomy or hepaticojejunostomy
Delayed Detection

51. • Strasberg Type E2 and E3 injuries require
anastomosis with left hepatic duct
(Hepp-Couinaud technique)
• When confluence is disrupted (E4 injury),
separate anastomoses with right and left
hepatic ducts are required.
• Anastomotic stoma should be adequate in size
to prevent subsequent stricture formation
Delayed Detection

52. Hepp-Couinaud Technique
(French Connection)

53. Choice of Incision
• Hockey stick incision
• Midline incision
• Right paramedian
incision

54. Identification of left duct
• Anterior surface of liver is mobilized
• Adhesions between viscera and underside of liver are
cleared
• Round ligament is a useful tractor
• Key maneuver is to dissect down face of segment 4b of
liver, after clearing gallbladder fossa and segments 2, 3,
and 5

55. Identification of left duct
• A second useful
maneuver is to divide
the bridge of liver
tissue between
segment 3 and 4B,
when it is present
• LHA should be
identified at this stage
and slinged

56. Identification of left duct
• Fibrous liver plate is
encountered, lower
down the hilar liver
plate
• The left hepatic duct
can be felt at this
point and confirmed
by aspiration with a
fine needle

57. • It is opened longitudinally between stay sutures using
a scalpel with a small blade and then Pott’s scissors.
• End to side enterohepatic anastamosis is made using
5/0 monofilament absorbable interrupted sutures

58. Complications
• Delayed stricture formation at anastomotic
site can be managed by repeated balloon
dilatations. It is placed endoscopically and left
in situ
• Cholangitis is treated with broad spectrum
antibiotics

59. Summary
• Multidisciplinary management of BDI requires
expertise of surgeon, radiologist & endoscopist
• Mismanagement leads to lifelong disability &
chronic liver disease
• Results of operative repair for iatrogenic BDI are
excellent in specialised centres

60. Thank you