This document discusses safe laparoscopic cholecystectomy and management of bile duct injuries. It begins with an overview of laparoscopic cholecystectomy and the increased risk of bile duct injury compared to open procedures. It then covers bile duct injury mechanisms, classifications, prevention techniques such as obtaining the critical view of safety, and management strategies whether the injury is recognized intraoperatively or postoperatively. The key messages are that obtaining the correct anatomical views and following established safety procedures can help prevent bile duct injuries, and injuries need to be promptly addressed either by repair or biliary reconstruction to reestablish bile flow.

1. SAFE LAPAROSCOPIC CHOLECYSTECTOMY
AND
BILE DUCT INJURY AND MANAGEMENT

2. SEQUENCE OF FLOW
 HISTORY AND BACKGROUND
 OVERVIEW OF LC AND BILE DUCT INJURY
 BILIARY INJURY MECHANISM & CLASSIFICATIONS
 PREVENTION
 MANAGEMENT OF BILE DUCT INJURY
 CONCLUSION

3. HISTORY AND BACKGROUND
• Most common surgical procedures
performed- with over 750,000 *
• Open cholecystectomy- Carl
Langenbuch in 1882
• In 1985, the first Laparoscopic
cholecystectomy (LC)- Erich Mühe
of Bšblingen, Germany.
* Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones.
Gastroenterol Clin North Am 2010;39:157–169

4. OVERVIEW
• Over 80% of -laparoscopic approach *
• Advantages of laparoscopic over open
cholecystectomy
* Keus F, et al. Laparoscopic versus open cholecystectomy for patients
with symptomatic cholecystolithiasis. Cochrane Database Syst Rev
2010;CD006231.

5. OVERVIEW…
• LC is the gold standard for management of
gallstones.
• Iatrogenic Bile Duct Injury- Two to three times
greater than the open procedure
• 3 per 1,000 procedures performed *
* Buddingh KT, Weersma RK, Savenije RA, van Dam GM, Nieuwenhuijs VB. Lower rate of major bile duct
injury and increased intraoperative management of common bile duct stones after implementation of
routine intraoperative cholangiography. Journal of the American College of Surgeons 2011; 213:267-74.

7. ANATOMY
a. Right hepatic duct.
b. Left hepatic duct.
c. Common hepatic duct.
d. Portal vein.
e. Hepatic artery.
f. Gastroduodenal artery.
g. Right gastroepiploic artery.
h. Common bile duct.
i. Fundus of the gallbladder.
j. Body of the gallbladder.
k. Infundibulum.
l. Cystic duct.
m. Cystic artery.
n. Superior
pancreaticoduodenal artery.
Schwartz‟s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

8. BLOOD SUPPLY TO CBD
The cranial segments :
cystic artery especially the
right hepatic artery.
The caudal segment:
pancreaticoduodenal artery
through the retroduodenal
artery.
The middle segment :
arterial anastomoses between
the cranial and caudal
supplies.

9. BLOOD SUPPLY

10. IATROGENIC BILIARY INJURY -
ETIOLOGY

11. ETIOLOGY
PATHOLOGICAL FACTOR
• Acute cholecystitis
• Acute biliary pancreatitis
• Bleeding in calot’s triangle
• Severely scarred or
shrunken gall bladder
• Difficult GB
TECHNICAL FACTOR
• 02 Dimensional
operative field
• Classic bile duct
injury
• Cognitive factors of
surgeons
• Skill of surgeon
Maingot’s abdominal operation- 12th ed

12. ETIOLOGY
ANATOMIC FACTOR
Abnormal biliary anatomy
• Short cystic duct, cystic duct
entering in the right duct
• Accessory right hepatic duct
Arterial anomalies
• Right hepatic artery running
parallel to the cystic duct
• Anomalous or accessory
right hepatic artery
PHYSIOLOGIC FACTOR
• Ischemia of bile duct
from excessive
periductal dissection

13. BILE DUCT INJURY- CLINICAL
PRESENTATION, INVESTIGATIONS
AND CLASSIFICATION

14. • Almost 85% of IBDI are not recognized- surgical
procedure*
• Only 15%-30% of IBDI are recognized during the initial
operation**
• 70% of IBDI are diagnosed within 6 months and 80%
within 12 months after the initial operation***
*De Wit LT, Rauws EA, Gouma DJ. Surgical management of iatrogenic bile duct injury.
Scand J Gastroenterol Suppl 1999; 230: 89-94
**Gouma DJ, Obertop H. Management of bile duct injuries: treatment and long-term
results. Dig Surg 2002; 19: 117-122
***Hall JG, Pappas TN. Current management of biliary strictures. J Gastrointest Surg
2004; 8: 1098-1110
FACTS

15. CLINICAL PRESENTATION
• Depends on type of injury and divided into groups:
 leak
 Stricture

16. Radiological investigations
• Ultrasonagraphy and CT – Ductal
dilatation intra-abdominal collection
and dilatation of biliary tree.
• Cholangiogram
• ERCP—biliary anatomy and assess
the injury
• PTC—define biliary anatomy proximal
to injury
• MRCP—noninvasive (can miss minor
leaks)
• HIDA scan -- If doubt exists, HIDA
scan can confirm leak but not the
specific leak site
• MR angiography—vascular injuries

17. Classification of bile duct injury(BDI)
 Bismuth-Corlette classification
 Strasberg classification
 Stewart-Way classification
 Lau classification
 Hannover classification
 Mattox classification

18. Bismuth classification

19. Strasberg classification

20. HOW TO AVOID IBDI ??

21. HOW TO AVOID BDI ??..
1. Correct exposure and identification
• “ Critical View Of Safety”
• Rouviere’s sulcus (RS)
2. Avoid error trap
3. Thermal injuries
4. Blind hemostasis
5. IOC
6. Surgeons characterstics

22. HOW TO AVOID BDI ??..
Strasberg in 1995- “Critical View of Safety” (CVS) *
1. Meticulous dissection of the Calot’s triangle from all
fatty and fibrous tissue.
2. Lowest part of gallbladder should be separated from
the cystic plate, which allows the visualization of
posterior liver bed.
3. Dissection and identification of only two structures
(cystic duct, cystic artery) entering the gallbladder.
* Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic
cholecystectomy. J Am Coll Surg. 1995;180(1):101–25.

23. Critical View of Safety(CVS)

24. Critical view of safety anterior view Critical view of safety posterior view

25. SAGES 6 STRATEGIES
1. Critical View of Safety (CVS)
2. Intra-operative time-out prior to clipping, cutting or
transecting any ductal structures is advised.
3. Variations in anatomy should be considered in all cases.
4. Surgeon should use cholangiography or other instrument
for demonstrating biliary anatomy.
5. In case of difficulty to expose biliary anatomy alternatives
surgical techniques such as partial cholecystectomy,
cholecystostomy tube placement or conversion to an open
procedure
6. Consultation with an another surgeon in difficult cases may
be helpful.
SAGES (Society of American Gastrointestinal and Endoscopic Surgeons), 2008.

26. Rouviere’s sulcus (RS)

27. HOW TO AVOID BDI ??...
Error traps in laparoscopic
• Infundibular technique error trap
• Fundus down error trap
• Failure to perceive the presence of an aberrant right
hepatic duct on cholangiography
• “parallel union” cystic duct
STEVEN M. STRASBERG. Error traps and vasculo-biliary injury in laparoscopic and open
cholecystectomy. J Hepatobiliary Pancreat Surg (2008) 15:284–292

28. Infundibular technique error trap

29. Fundus down error trap

30. Failure to perceive the presence of an aberrant right
hepatic duct on cholangiography

31. “Parallel union” cystic duct

32. HOW TO AVOID BDI ??...
THERMAL INJURIES
• Misuse of cautery in dissecting the Calot’s triangle
• Not to use cautery to cut the cystic duct
AVOID BLIND HAEMOSTASIS
INTRAOPERATIVE CHOLANGIOGRAM (IOC)
SURGEONS CHARACTERISTICS OF RISK TAKING

33. CLASSIC BILIARY INJURY
• CBD is mistaken for cystic duct often includes injury
to RHA as it enters either above or below hepatic
duct
Maingot’s abdominal operation- 12th ed

34. Management of Strategy When Faced with
IBDI

35. 1. INTRA OP MANAGEMENT
2. DELAYED MANAGEMENT

36. Treatment of BDI
1. Endoscopic and radiological treatment
2. Surgical treatment
 End-to-end Ductal Biliary Anastomosis (EE)
 jejunal interposition hepaticoduodenostomy
 Roux-en-Y HJ
 Blumgart (Hepp) anastomosis
 Heinecke-Mikulicz -biliary plastic reconstruction
 Smith mucosal graft

37. Recognition of BDI intraoperatively
• Immediate cholangiography and conversion to
an open procedure in order to define the extent of
the injury are required.
• Bile ducts of diameter < 3 mm -should be ligated
• Bile ducts of diameter > 3 mm should be repaired
• Interruption of common hepatic duct or
common bile duct continuity can be repaired by
immediate tension free EE with or without a T tube
SABISTON TEXTBOOK OF SURGERY – 20TH ED

38. • If the bile duct loss is too long and near the
bifurcation, EE is not possible without tension and
bilio-enteric anastomosis (Roux-en-Y HJ vs
choledochoduodenostomy) is recommended.

39. If detected in Post-Operative period
1. Control of infection limiting inflammation
 Parenteral antibiotics
 Percutaneous drainage of periportal fluid
2. Clear and thorough delineation of entire biliary
anatomy
 PTC
 ERCP/MRCP
3. Re-establishing biliary enteric continuity
 Tension free , mucosa to mucosa
SABISTON TEXTBOOK OF SURGERY – 20TH ED

40. Conclusion
• LC which is a gold standard therapeutic option
• Using well-described anatomical landmarks and fixed
extra biliary reference points, combined with other well
documented strategies should be followed

41. TAKE HOME MESSAGE
• The primary goal of LC is ‘‘safety first, total
cholecystectomy second.’’
• “Culture of safety”
• Failure - increase health care expenses, impaired
quality of life, and may even lead to death.
1. Critical View of Safety (CVS)
2. Variations in anatomy
3. Alternatives surgical techniques
4. Consultation with an another surgeon in difficult
cases may be helpful
5. Reporting of cases

42. THANK YOU !!!