This document discusses bile duct injuries (BDI) that can occur during cholecystectomy. It notes that BDI are rare but potentially devastating, and are most commonly caused by laparoscopic cholecystectomy. The document covers anatomy of the bile ducts, classifications of BDI, risk factors, prevention techniques like obtaining the "critical view of safety", and management approaches depending on the type and timing of injury identification. For injuries identified during surgery, the goal is usually repair or reconstruction. For later injuries, management involves drainage, antibiotics, and definitive reconstruction once inflammation decreases. Surgical repair via Roux-en-Y hepaticojejunostomy is often needed but endoscopic or radiologic techniques can sometimes be

1. DR AAMIR HELA

2. Introduction
Bile ductinjury(BDI)
 Rarebutpotentiallydevastating condition
 Biliaryperitonitis&sepsis,cholangitis,portal
hypertension&secondarybiliary cirrhosis
 Significantmorbidity& mortality
Iatrogenic BDI
 Increasedfinancialburden(patientor hospital)

3. Anatomy
Calot’s triangle–between
inferiorsurfaceofliver,Cystic
duct&CHD
Contents –Cysticartery,
RHA,Cysticlymph node

4. BileDuctInjuries (BDI)
Iatrogenic injury
 Cholecystectomy
 Gastrectomy
 Pancreatectomy
 ERCP
Trauma
Duodenal ulcer

5. Riskfactors
Inflammation intheporta,
Variable biliaryanatomy,
Inappropriate exposure,
Aggressive attemptsat hemostasis,
Surgeon inexperience.
97% dueto visual misperception, only3%accountsfor
technicalskillsand knowledge.

6. Misperception ..
With sufficient cephalad retraction of the gall bladder
fundus ,the cystic duct overlies the common hepatic duct
running in a parallel path without inferolateral traction of
the gall bladder infundibulum to dossociate this
structures, the dissection of apparent cystic duct may
actually include CBD…

7. ClassicalLCBDI

8. Laparoscopiccholecystectomy(LC)
Gold standardformanagementofbenigngallbladder disease
Compared withlaparotomy
 Lesspost-op pain
 Shorterhospital stay
 Earlierreturntonormal activity
 Bettercosmesis
 Iatrogenicbileductinjury rate
 0.1%to0.2%(open)vs0.4%to0.6%(lap)
‘’Learning curvephenomenon’’

9. LC&Bileductinjury(BDI)
LC mostcommoncauseofBDI
More severethanthoseseenwithOpen chole
’Learning curve phenomenon’’
BDI afterLCstablearound 0.6 to0.7%, 4timesthatofopen
chole–highforabenigncondition

10. Classification
location ofinjury
mechanism &typeofinjury
effect onbiliarycontinuity
timing of identification
Eachplayssignificantroleindeterminingappropriate
management&operativerepair

11. ClassificationofBDI
Bismuthclassification(1982)
Era ofOpenChole
Based uponlevelofbiliarystrictureswithrespecttohepatic
bifurcation
Type 1-5.
Helps surgeonchooseappropriatesitefor repair
Degree ofinjurycorrelateswithsurgical outcomes

12. Strasbergclassification(1995)
A LeakfromCysticductorsmallductsinliverbed
B Injury to sectoral duct ( aberrant RHD) with
obstruction
C Injury tosectoralduct withconsequentbileleak
D Lateralinjurytoextrahepatic duct
E1 Transection >2cmfromtheconfluence
E2 Transection <2cmfromtheconfluence
E3 Transectionattheconfluence
E4 Separation of majorducts intheconfluence
E5 Completeocclusionofallbile ducts.

13. Strasbergclassification

14. ClinicalPresentation(post-op)
Obstruction
 ClipligationorresectionofCBD obstructive
jaundice, cholangitis.
Bile Leak
 Bilefromintra-opdrain or
 Morecommonly,localizedbilomaor freebileascites/
peritonitis, if nodrain
 Fever,abd pain, jaundice,orbileleakagefrom incision.
 Diffuse abdominalpain& persistent Ileusseveraldays
post-op highindexofsuspicion possible
unrecognized BDI

15. Reasons
Misidentification
 CBDoraberrantRHDmistakenforcysticduct
 Riskfactors inexperience,inflammationoraberrant
anatomy
 Infundibulartechnique– flaring of cysticductasit
becomesinfundibulum  misleadingininflammation
Technical errors
 Cauteryinduced injury

16. Prevention
 30°laparoscope,highqualityimaging equipment
 Firmcephalictractiononfundus&lateraltractionon
infundibulum,socysticductperpendicularto CBD
 Dissectinfundibulo-cystic junction
 Expose“Criticalviewofsafety”beforedividingcystic duct
 Converttoopen,ifunabletomobiliseinfundibulumor
bleedingorinflammationinCalot’s triangle
 Routineintra-opcholangiogram
 “Fundus-first”dissection

17. Criticalviewof safety
Calot’s triangle dissected frree
of all tissue except cystic duct
&artery
Base ofliverbedexposed
When thisviewisachieved,
thetwostructuresenteringGB
canonlybecysticduct&
artery

18. CysticductorCBD?
CautionCysticduct CBD
2– 3mmwide 5mmwide CD >5mm– Isit CBD?
duct insertion, CD
rarely goesbehind
duodenum
Even withlowcystic CBDgoesbehind
duodenum
Ductbehindduodenum
mustbe CBD
Doublecysticduct
veryrare
-- 2ductsseemtogotowards
inflammedGallbladder–
onemustbe CBD
Novesselson
surface
Vesselson
surface
--

19. Management

20. Recognizedat theTimeofCholecystectomy
Conversion toanopenoperationanduse of
cholangiography.
Goals ..
Maintenanceofductallength,eliminationofanybile
leakagethatwouldaffectsubsequentmanagement,and
creationofatension-free repair.

21.  Ducts smaller than3mmdrainonlyasinglesegment
orsubsegmentofliver..simple ligation.
 Ducts larger than3mmusuallydrainmorethanasingle
segmentofliver,if transected..shouldbereimplantedinto
thebiliary tree.
 Injury occurstoalargerduct,butisnotcausedby
electrocauteryandinvolveslessthan50%ofthe
circumferenceofthewall,aTtubeplacedthroughthe
injury

22.  Lowinjuriestothebileductcanbereimplantedintothe
duodenum.
Most injuriestothebileductoccurhigherinthebiliarytree,
closetothehilum,thusnotallowingfortension-freeanastomosis
totheduodenum.Therefore,inalmostallcasesofbileduct
injury,aresectionoftheinjuredsegmentwithmucosato
mucosaanastomosisusingaRoux-en-Yjejunallimb(end-
to-sidecholedochojejunostomy) is preferred.
Transanastomotic stentinghasbeenshowntoimprove
anastomoticpatency.

23. Identified After Cholecystectomy
GoalsofTherapyin Iatrogenic bile DuctInjury
1. Controlofinfectionlimiting inflammation
•Parenteralantibiotics Percutaneousdrainage
2. Clear andthorough delineation of entire biliary
anatomy.
MRCP/PTC,ERCP
3.Re-establishmentofbiliaryenteric continuity
•Tension-free,mucosa-to-mucosaanastomosisRoux-en-Yhepaticojejunostomy
•Long– termtransanastomoticstentsif involvingbifurcationorhigher

24. Approach..
Should undergo imaging to assess for a fluid collection and
evaluatethebiliary tree.
• Ultrasonography canachieveboththese goals.
• Cross-sectional imaging via CT will generally provide more
usefuldata.
• Radionucleotide scanning to confirm bile leakage, but
with anydocumentationof aleak, CTwill benecessaryto
planmanagement.

25. CT orU/Sguided(orsurgical)drainage
Sepsis control Broad-spectrumantibiotics&
percutaneousbiliarydrainagetocontrolanybileleak
  mostfistulaswill becontrolledorevenclose.
1.5% mortalityrateduetouncontrolled sepsis
No rushtoproceedwithdefinitivemanagementofBDI.
Delay ofseveralweeksallowslocalinflammationto resolve
&almostcertainlyimprovesfinaloutcome.

26. Definitive managementistoreestablishdurablebiliary
enteric drainage.
Combination ofpercutaneousandendoscopicbiliary
dilationsandstentingmayestablishcontinuity.
Surgical reconstructionhasthehighestpatency rates.
performed betweenaminimallyinflamedbileductto
intestinesinatension-free,mucosatomucosafashion.

27.  If theanastomosisiswithin2cmofthehepaticduct
bifurcation,orinvolvesintrahepaticducts,long-termstenting
appearstoimprove patency
 I f thebifurcationisinvolved,stentingofbothrightandleft
ductsshouldbe performed
When the reconstruction involves thecommonbile duct or
commonhepaticductmorethan2cmfromthe bifurcation,
stentingisnot necessary.

28. InterventionalRadiologicandEndoscopicTechniques
Using balloondilationtechniques,thestrictureisdilatedand
acatheterisleft inplacetodecompressthesystem,allow
healing,documentresolutionand,if necessaryguiderepeat
dilations.
This approachissuccessfulinupto70%ofpatients.
Endoscopic balloondilationofbileductstricturesisgenerally
reservedforthosewithprimarybileductstricturesorpatients
whohaveundergonecholedochoduodenostomyfor
reconstruction,becausetheRouxlimbdoesnotusuallyallow
forendoscopic strategies.

29.  Tw o large retrospective reviews have been performed and
both have shown higher success rates from surgical
therapy, with lower morbidity and lower mortality
following operative management compared with those for
nonoperative strategies

30. ERCP–multiplestents
Lateral ductwallinjuryor
cysticductleak 
transampullarystentcontrols
leak&providesdefinitive
treatment
Distal CBDmustbeintact to
augmentinternal
drainagewithendoscopic
stent

31. ERC–clipsacrossCBD
CBD transection 
normal-sizeddistalCBD
uptositeof transection
Percutaneous transhepatic
cholangiography(PTC)
necessary
Surgery

32. Cholangiography(ERCP+PTC)
Percutaneous transhepaticcholangiography (PTC)
 Definesproximal anatomy
 Allowsplacementofpercutaneoustranshepaticbiliary
catheterstodecompressbiliarytree treatsor
preventscholangitis&controlsbile leak

33. MRCP/CTcholangiography
Noninvasive
May avoidinvasiveprocedureslikeERCPorPTC
Do notallowintervention
Interpretatation inpresenceofbilecollection difficult

34. Biliaryentericanastomosis
Most laparoscopicBDI –
complete discontinuity of
biliary tree
Surgical reconstruction,
Roux-en-Y
hepaticojejunostomy
tension-free, mucosa-to-
mucosaanastomosiswith
healthy,nonischemicbile duct

35. Treatmentsummary
Strasberg TypeA–ERCP+sphincterotomy+stent
Type B&C–traditionalsurgical hepaticojejunostomy
Type D–primaryrepairoveranadjacentlyplacedT-tube(if
noevidenceofsignificantischemiaorcauterydamageatsite
ofinjury)
More extensivetypeD&Einjuries–Rouxan-Y
hepaticojejunostomywithbiliary stent

36. Thank you…