bile duct injury classification and management

2. ⦿Despite experience - remains a significant
problem
⦿Incidence
◼Lap chole 0.3-0.6%,
◼Open chole 0.1-0.2%
⦿In Lap
◼More often
◼Major injury
◼More proximal duct

3. First planned cholecystectomy
• by Carl Langenbuch in 1882.
First iatrogenic bile duct injury
• described by Sprengel in 1891.

4. Erich Muhe
1985 Germany
Philippe Mouret
1987 France
They made it feasible, let us make it safe!...

5. ⦿Visual misperception
⦿Looking at 2D while working in 3D

6. We see what
we want to see

7. ⦿Misidentification of
bile duct as cystic duct
⦿Classical BDI
⦿Bile duct is cut twice to remove
the GB

8. BDI
anatomy pathology technique

9. ⦿Classic anatomy of biliary tree is present in
only 30% of individuals,
Anomalies are rule, Not the exception.

12. ⦿Acute cholecystitis
⦿Pyocele
⦿Large stone in Hartmann’s pouch
⦿Impacted stone at cystic duct
⦿Wide and short cystic duct
⦿Mirrizi’s syndrome

13. ⦿Dissection injury ⦿Traction injury

14. ⦿Diathermy injury
⦿Inappropriate use of electrocautery near
biliary ducts may lead to
◼bile leaks and/or strictures later

15. Follow the steps of
safe
cholecystectomy
Look for cues of
bile duct injury
Use of imaging

16. ⦿Identify GB – cystic duct junction
⦿Elephant trunk sign
⦿Hidden cystic duct syndrome

17. ⦿Henri Rouviere – Prof. of Anatomy (France)
⦿Rouviere’s sulcus

18. Extra-biliary reference point
for
safe navigation

19. ⦿Strasberg’s Critical view (1995)
◼Concept of thorough dissection
◼and delineation of all the structure in the
hepatocystic triangle

20. ⦿Strasberg’s Critical view (1995)
◼Separate lower GB from liver bed to cystic plate
◼Only 2 structures entering gallbladder
◼Anterior and Posterior views required

21. ⦿Unclear anatomy
⦿Dangerous pathology
⦿Clips are small for the duct
⦿Unusual field of vision
◼More duodenum, less liver
Red Flag signs of BDI
⦿Recognize difficult cholecystectomy, be more
cautious; Get help for difficult cases.
⦿Always feel free to Convert or Consult

22. ⦿Traditional Intraoperative cholagiogram
⦿Consider whenever in doubt,
◼Unclear anatomy
◼Suspected bile duct stones
⦿May not prevent BDI, but could aid its early
recognition

23. ⦿Intra-op USG

24. ⦿Fluorescence cholangiography
◼Indocyanine Green binds to plasma proteins
(primarily albumin) and is taken up by hepatic
parenchymal cells (secreted entirely into bile)
◼ICG absorbs light in the NIFR (806nm) and emits
light at a longer wavelength (830nm)

25. ⦿Safe & effective, faster and easier than IOC
⦿Pitfalls
◼choledocholithiasis, occluded cystic duct
⦿Hurdles to use –
◼Initial investment, Continued equipment cost

26. ⦿ The first classification of bile duct injury,
authored by H. Bismuth in 1982.
⦿ Based on the location of the injury in the biliary
tract from bile duct bifurcation, the involvement
of bile duct bifurcation, and individual right
sectoral duct.

27. ⦿Type A
◼Cystic duct leaks or
◼Leaks from small ducts in liver bed
⦿Type B
◼Occlusion of aberrant right hepatic ducts
⦿Type C
◼Transection of aberrant right hepatic ducts
⦿Type D
◼Partial (<50%) transection of major bile duct

28. ⦿ Type E of the Strasberg classification is an
analogue of the Bismuth classification.

29. ⦿ Allows differentiation between bile leakage from
the cystic duct or aberrant right sectoral branch
and injuries performed during laparoscopic
cholecystectomy.
⦿ Drawback – No information of vascular injury.

30. ⦿Proposed by Bektas et al.

31. ⦿Proposed by Bektas et al.

32. ⦿Proposed by Bektas et al.

33. ⦿Proposed by Bektas et al.

34. ⦿Proposed by Bektas et al.

35. ⦿Vascular injuries are included in Type C and
Type D .
⦿This classification provides the location of
tangentially or completely transected bile
ducts above or below the bifurcation of the
hepatic duct.
⦿Also, describes associated vascular injuries.

36. ⦿Be calm
⦿Don’t panic
⦿Shouting on assistants will not solve the
situation
⦿One minute rule
⦿Assess complexity
⦿Assess your experience
⦿Call for help (colleague assistance)

37. ⦿Decision
⦿Fix now
◼Reduced morbidity, duration of illness, cost.
⦿Fix later
Lap open

38. ⦿Aberrant right sectoral hepatic duct
◼suture
◼Drain + delay repair
⦿Small / simple laceration
◼Consider repair with 4-0 absorbable suture
(extensive dissection increases stricture rate)
⦿Non circumferential laceration
◼Repair over T tube.

39. ⦿Complete transsection
⦿End to end repair over T tube, 4-0 absorbable
suture
◼Risk of stricture
⦿Roux-en-Y Hepaticojejunostomy
◼preferred

40. ⦿Place catheter in proximal duct
⦿Place drains
⦿Avoid laparotomy just for drain
⦿Refer to tertiary care centre
◼(experienced surgeon)
⦿GOAL:
◼Drain / control of sepsis
◼Maintain CBD length

41. ⦿Do not worsen an already bad situation
⦿If a BDI occurred make sure you avoid a
second mistake
⦿This is not the time to do your once a year
hep-jej
⦿Experienced surgeon:
◼94 Vs 17% success rate
⦿Success of repair is inversely proportional to
the number of operative attempts

42. ⦿Bile leak
◼Pain, bile in drain, signs of peritonism
⦿Biliary obstruction
◼Abnormal LFT, Jaundice, cholangitis

43. ⦿US/CT abdomen
◼To look for any collection/Guided drainage
⦿HIDA scan
◼Confirms leak but fail to give anatomic detail we
need

44. ⦿PTC
◼To visualize the proximal ducts and assess the
grade of injury
⦿MRCP
◼Non-invasive test of choice to assess the grade of
injury
◼Both proximal and distal ducts can be seen and
leaks also can be identified

45. ⦿ERCP
◼Delineate distal ducts.
◼Mainly for therapeutic purpose/ operator
dependent

46. ⦿Minor leak
⦿US/CT Guided Drainage
⦿ERCP and sphincterotomy ± Stenting
⦿Major leak
⦿Repair ± T-tube
⦿Hepatico-jejunostomy

47. ⦿Presentation
◼depends upon the drainage area
⦿Aymptomatic
⦿Fever, pain, malaise
⦿Cholangitis
⦿Jaundice
⦿Management
⦿Antibiotic ± Drainage
⦿May require Hepatico-jejunostomy

48. ⦿Hepatico-jejunostomy

49. ⦿The desired pre-requisites are as with any
anastomosis
⦿Well vascularised ducts
⦿Repair without tension
⦿Largest possible diameter
⦿Mucosa to mucosa apposition
⦿Single layer repair
⦿Absorbable monofilament suture

51. ⦿Surgeon’s factors
⦿Failure to inform the patient of the risks
involved in the procedure.
⦿Poor documentation
◼Not documented, not done
⦿Poor safety procedures
⦿Lack of transparency
◼If there is complication, be transparent and
truthful and get a specialist involved early.
⦿Delay in diagnosis

52. ⦿Good documentation can save you
⦿A detailed consent form including all possible
risks associated with procedure discussed
thoroughly with patient and family,
◼can prevent/reduce the risk of a medico-legal suit
being filed, and even if filed, being decided in the
patient’s favor
⦿Make sure, you have good insurance
⦿Find a legal team you trust.
⦿Do not research the patient’s chart or talk
with others about the case unless directed to
do so