This document discusses bile duct injuries that can occur during cholecystectomy. It provides background on the history and burden of bile duct injuries. The incidence varies from 0.1-0.6% depending on the type of procedure (open vs laparoscopic). Bile duct injuries can have devastating consequences for both patients and surgeons, including significant morbidity, mortality, economic costs, litigation, and loss of confidence or job for surgeons. Various patient factors, anatomical variants, pathology, misinterpretation of structures, and failures during surgery can all contribute to the mechanism of bile duct injuries. Achieving the critical view of safety during surgery and understanding dangerous anatomy are emphasized as ways to help prevent such injuries.

1. POST CHOLECYSTECTOMY
BILE DUCT INJURIES
Dr Sujan Shrestha
MCh, Second year
TUTH, IOM

2. Burden of bile duct injury
Carl Langenbuch
Germany on 15 July 1882
Eric Muhe
Germany 1985 France 1987
Philip Mouret
Open cholecystectomy
Direct laparoscopy
Video laparoscopy

3. Burden of bile duct injury
W J Mayo
1905
First two cases of
hepaticoduodenostomy for
bile duct injury following
open cholecystectomy
Annals of surgery
23 yrs after first
reported open
cholecystectomy

4. BDI is an uncommon
Incidence
• 0.1– 0.2% in open cholecystectomy
• 0.4–0.6% in laparoscopic
cholecystectomy
McMahon AJ Br J Surg. 1995
SILS
Incidence of bile duct injury is 0.72% (case selection bias)
Mark Joshep, annals of surgery. 2012
ROBOTIC
Incidence of bile duct injury is
5 cases of bile duct injury out of 925 cases
Baek NH , Hepatogastroenterology. 2015
Burden of bile duct injury

5. Burden of bile duct injury
BPKIHS
Narendra Pandit, Minimal invasive surgery, 2020
Incidence of bile duct injury 0.78%
Incidence was 0.3 (2013 published data)
KMC
Udaya Koirala, JNHRC, 2011
Incidence of bile duct injury 2.6%
LMC
Narad Prasad Thapaliya, JCMC, 2018
1 case of bile duct injury out of 372 cases
NOBEL
Ruslan Sulaimankulov, hvt journal, 2019
Incidence of bile duct injury is 0.9% (7557 patients
over 8 yrs)
NEPAL

6. CONSEQUENCES OF BILE DUCT INJURY
Devastating complication of cholecystectomy—
Both for patient and operating surgeon
Patient
Morbidity (40-50%)
• Physical
 Bile leak associated
 Biliary stricture associated
• Mental and social
 Health quality of life (SF26) worse in 3-7 out of 8 domain when compared to patient who
underwent noncomplicated lap chole (de Reuver PR, Endoscopy. 2008)
 Patient usually resume 3 months late to non complicated lap chole counterpart.
• Economical
 Hospital cost (direct and indirect)
 Loss of work
 Use of disability benefit
Mortality
• 2-4 %
Schreuder A.M, et, al. Digestive surgery, 2020.
The life-time hazard ratio of death, either immediately or
later, due to a BDI sustained during cholecystectomy is
2.8 (as compared to patients who had an uneventful
cholecystectomy with no BDI
Flum DR, JAMA.
2003

7. CONSEQUENCES OF BILE DUCT INJURY
Patient
Economical Morbidity
• “Financial disaster” as the costs of management of a BDI are 5–26
times the costs of a cholecystectomy.
• The mean cost of management of common bile duct transection/excision
increased to US$ 9061 from the mean cost of US$ 2681 for an uncomplicated
cholecystectomy.
• The median total cost of the management of BDI was INR 93,046 (range 22,204-
562,790). 15–20 times the cost of an uncomplicated cholecystectomy
• Indirect cost including the loss of wages, attendant cost and much other are not
included
Woods MS.. Surg Endosc. 1996
VK Kapoor. 2020

8. CONSEQUENCES OF BILE DUCT INJURY
Patient
Economical Morbidity
HPB surgery, 2011
Cost and
mortality of
• grade I
($12,457,
0%),
• Grade I injuries
involve the duct of
Luschka or accessory
right hepatic ducts,
• Grade II includes
Classification

9. CONSEQUENCES OF BILE DUCT INJURY
Surgeon
The second victim as per patient safety classification
Bailey and love 26th edition
Physical
• MOB mishandle
Mental
• Lost of job
• Social stigma
• Loss of confidence
• Depression

10. CONSEQUENCES OF BILE DUCT INJURY
Surgeon
Litigation
• For Lay people BDI is always health error or negligence on surgeons' part
• Litigation claim incidence
 4-6 per 10,000 cholecystectomies in UK.
 About 0.08% of laparoscopic cholecystectomies in Netherland.
 81 (78%) out of 104 litigations following laparoscopic cholecystectomy were related to
BDI, vascular injury (7%), bowel injury (2%), and other injuries (13%)
Gossage JA, Int J Clin Pract. 2010.
de Reuver PR, J Am Coll Surg. 2008
McLean TR. Arch Surg. 2006

11. CONSEQUENCES OF BILE DUCT INJURY
Surgeon
Compensation
• Most of the cases goes in favor of patients
• Surgeon or associated health institute usually land off with huge compensation
• Compensation in the UK ranged from £ 40,000 to 100,000
• Compensation in the USA ranged from US$ 214,000 - US$ 508,341
Gossage JA. Int J Clin Pract. 2010
McLean TR Arch Surg. 2006.

12. MECHANISM OF BILE DUCT INJURY
DANGEROUS
DISEASE
DANGEROUS
ANATOMY
DANGEROUS
SURGERY
BILE DUCT INJURY
MISINTERPRETATION MISINTERPRETATION

13. MECHANISM OF BILE DUCT INJURY
Visual Perception Error
• Misidentification of duct due to cognitive fixation
• Huristic nature of human visual perception
हो क
े गारन्टी 100%
KANIZSA’S TRIANGLE

14. MECHANISM OF BILE DUCT INJURY
DANGEROUS PATHOLOGY
1. Acute cholecystitis and its associated complications
Operate with in 3 days or after 6 wks
Better in hand of HBP surgeon

15. MECHANISM OF BILE DUCT INJURY
DANGEROUS PATHOLOGY
2. Chronic cholecystitis
3. Hidden cystic duct
• Large stone impacted in the gallbladder
neck,
• Short/absent cystic duct,
• Acute cholecystitis, and

16. MECHANISM OF BILE DUCT INJURY
DANGEROUS PATHOLOGY
4.
5. Cirrhosis and portal hypertension

17. DANGEROUS PATHOLOGY
MECHANISM OF BILE DUCT INJURY
6. Others
• Previous acute pancreatitis
• Previous cholangitis
• Previous ERCP
• Xanthogranulomatous cholecystitis

18. MECHANISM OF BILE DUCT INJURY
Patient related factors
Elderly
Male patient
High BMI
VIP patient
Waage A. Arch Surg. 2006.
VK Kapoor, 2020.
Sir Anthony Eden
• Underwent open cholecystectomy on 12th April 1953.
• Reexplored on 29th April.
• He was then flown to the USA where repair of a bile duct
injury was performed by Richard Cattell of the Lahey Clinic
on 10th June.
• He underwent a total of as many as 4 operations including
a liver resection
• He died on 5th March 1970.

19. MECHANISM OF BILE DUCT INJURY
Patient related factors
VIP patient VK Kapoor, 2020.
US Senator John Murtha, a Democratic Congressman
• Laparoscopic cholecystectomy on 28th
January 2010 at the National Naval
Medical Center in Bethesda
• 3 days later—he died on 8th February
2010.
• It is alleged that the doctors had “hit his
intestines.” Personal experience
• Operation theater staff(gall
bladder)
• Medical student mother(gall
bladder)
• Medical student(appendix)

20. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
NORMAL VARIANT
57%
EVERY SECOND PATIENT OF
CHOLECYSTECTOMY MAY HAVE
ABNORMAL ANATOMY
SO KNOWLEDGE OF POSSIBLE VARIANT
OF RELEVANT BILIOVASCULAR
ANATOMY IS MUST

21. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
Triangle of Calot’s is content of hepatocystic triangle

22. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
SUBVESICAL DUCT CLASSIFICATION
SURGICAL RELEVANCE
1. For type 1 and type 2 leak stent placement
2. For other 2 types no role of stent
Thomas Schnelldorfer J Gastrointest Surg (2012)

23. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
CLINICAL SIGNIFICANE
• DO NOT LEAVE THE GALL BLADDER
• ALWAYS HUG THE GALL BLADDER
• DO NOT MAKE ANY ATTEMPT TO LOOK FOR
CBD

24. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY

25. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
SO THREE TYPES
• TYPE 1 – NEAR CONFLUENCE
• TYPE 2 – AWAY FROM CONFLUENCE
• TYPE 3 - COMBINED

26. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY
85 % 15%

27. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY

28. SORRY FOR THE INCONVENIENCE

29. MECHANISM OF BILE DUCT INJURY
DANGEROUS ANATOMY

30. MECHANISM OF BILE DUCT INJURY
ARTERIAL SUPPLY OF BILIARY SYSTEM
• Both intrahepatic and extrahepatic biliary system are
totally depended upon arterial supply.
• About 50 % of hepatic arterial supply is for biliary
system
Two main marginal artery
3 and 9 o'clock artery
Two thirds of arterial input came from ascending vessels
and only one third from descending vessels.
Ascending vessel
• PSPDA
• Gastroduodenal
• Supraduodenal
• Retroportal artery
Descending vessel
• Cystic artery
• Rt hepatic artery

31. MECHANISM OF BILE DUCT INJURY
ARTERIAL SUPPLY OF BILIARY SYSTEM
Axial pattern
Ladder MIXED

32. MECHANISM OF BILE DUCT INJURY
ARTERIAL SUPPLY OF BILIARY SYSTEM
• Communicating arcade
• Caudate arcade
• Transverse hilar marginal artery
Three tier vascular pattern of BILIARY SYSTEM

33. MECHANISM OF BILE DUCT INJURY
VENOUS DRAINAGE OF BILIARY SYSTEM
PARABILIARY VENOUS SYSTEM
Also called as accessory portal venous system
Petren – paracholedochal (external compression)
Saint – epicholedochal (irregular wall)
Subepithelial plexus (intraluminal varices- hemobilia)

34. MECHANISM OF BILE DUCT INJURY
Type I: Open type was defined as a cleft in which the right hepatic
pedicle was visualized and the sulcus was opened throughout its length.
Type II: if the sulcus was open only at its lateral end.
Type III If the sulcus was open only at its medial end.
Type IV: Fused type was defined as one in which the pedicle was not
visualized.
Rouviere’s sulcus
Prabin Bikram Thapa, JNMA, 2015

35. MECHANISM OF BILE DUCT INJURY
DANGEROUS SURGERY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
1. Critical View of Safety (CVS)
• The hepatocystic triangle is cleared of fat and fibrous tissue.
• The lower one third of the gallbladder is separated from the liver to expose the cystic plate.
• Two and only two structures should be seen entering the gallbladder

36. MECHANISM OF BILE DUCT INJURY
DANGEROUS SURGERY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
2. Understand the potential for aberrant anatomy in all cases

37. DANGEROUS SURGERY MECHANISM OF BILE DUCT INJURY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
3. Liberal use of cholangiography or other methods to image the biliary tree
intraoperatively.

38. DANGEROUS SURGERY MECHANISM OF BILE DUCT INJURY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
4. Intra-operative Momentary Pause prior to clipping, cutting or transecting any ductal structures

39. DANGEROUS SURGERY MECHANISM OF BILE DUCT INJURY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
5. Bail out

40. DANGEROUS SURGERY MECHANISM OF BILE DUCT INJURY
IDEAL SURGICAL PRINCIPLE
SAGES SIX SURGICAL STRATEGIES FOR LAP CHOLECYSTECTOMY
6. Call for help
Help can be
1. Visual colleaguography
2. Scrub assistant
VK Kapoor, 2020.

41. To be continued………..
• Management of bile duct injury
Thank you