The document discusses several classifications for bile duct injuries following cholecystectomy. The Bismuth classification from 1982 categorizes injuries based on location in the biliary tract into 5 types. The Strasberg classification from 1995 modifies Bismuth and allows differentiation between small and serious injuries from laparoscopic cholecystectomy as Types A-D, with Type E corresponding to Bismuth. The Stewart-Way classification from 2007 is based on injury mechanism and anatomy, categorizing injuries into 4 classes depending on whether the common bile duct was mistaken for the cystic duct and whether it was divided or the extent of injury. Associated vascular injuries also vary depending on the injury class.

1. Dr Karrar Adil

2. Introduction :
 Laparoscopic cholecystectomy is now the gold
standard for symptomatic cholelithiasis, but it is
associated with a higher incidence of bile duct
injury than open cholecystectomy.
 Numerous reports have demonstrated that the
incidence of bile duct injuries has risen from
0.1%-0.2% to 0.4%-0.7% from the era of open
cholecystectomy to the era of laparoscopic
cholecystectomy.

3.  Bile duct injury following cholecystectomy is an
iatrogenic catastrophe associated with significant
perioperative morbidity and mortality, reduced long-
term survival and quality of life.
 The ease of management, operative risk, and
outcome of bile duct injuries vary considerably, and
are highly dependent on the type of injury and its
location.
 Over the years, many classifications of IBDIs have
been occurred before and after the laparoscopic era
to ensure adequate treatment planning.

4. Bismuth classification :
 Is the first classification of bile duct injury, authored by H.
Bismuth in 1982.
 is a simple classification based on the location of the injury in
the biliary tract and is very helpful in prognosis after repair.
 was introduced before laparoscopy. It is difficult to apply in
laparoscopic cholecystectomy as most of the technical
factors and lesion mechanisms are completely different to
open surgery.
 This classification included five types of bile duct injuries
according to the distance from the hilar structure especially
bile duct bifurcation, the level of injury, the involvement of bile
duct bifurcation, and individual right sectoral duct.

5. • Bismuth type I : involves the common bile duct and low
common hepatic duct (CHD) >2 cm from the hepatic duct
confluence.
• Bismuth Type II : involves the proximal CHD <2 cm from
the confluence.
• Bismuth Type III : is hilar injury located at the confluence
with the ceiling of it still being intact.
• Bismuth Type IV : is destruction of the confluence when
the right and left hepatic ducts become separated.
• Bismuth Type V : involves the aberrant right sectorial
hepatic duct alone or with concomitant injury of CHD.

7. Strasberg classification 1995 :
 The Strasberg classification is a modification of
the Bismuth classification, is very simple which
can be easily applied to bile duct injuries.
 Allows differentiation between small (bile leakage
from the cystic duct or aberrant right sectoral
branch) and serious injuries performed during
laparoscopic cholecystectomy as type A to D.
Type E of the Strasberg classification is an
analogue of the Bismuth classification.

8. • Class A : Bile leak from cystic duct stump or minor ducts in
gallbladder fossa.
• Class B : Occluded right posterior sectoral duct.
• Class C : Transection without ligation of the right posterior sectoral
duct.
• Class D : Lateral injuries to major bile ducts.
• Class E : Subdivided as per Bismuth's classification into E1 to E5 :
 E1- Stricture/injury at more than 2 cm distal to bifurcation.
 E2 - Stricture/injury less than 2 cm distal to bifurcation.
 E3- Stricture/injury at bifurcation.
 E4 - Stricture/injury involving right and left hepatic ducts.
 E5 - Complete obstruction of entire bile duct.

10. Stewart-Way classification :
 Published in 2007.
 This classification system is based on the
mechanism and anatomy of bile duct injuries
and also includes concomitant vascular
injuries.
 Bile duct injuries fall into four classes
according to this classification :

11. Class I injury :
 Occurs when CBD is mistaken for
the cystic duct, but the error is
recognized before CBD is divided.
 Associated RHA injury (5%).

12. Class II injury :
 involve damage to CHD from clips or
cautery used too close to the duct.
 This often occurs in cases where visibility
is limited due to inflammation or bleeding.
 Associated RHA injury (20%)

13. Class III injury :
 the most common type.
 occurs when CBD is mistaken for the cystic
duct. The common duct is transected and a
variable portion including the junction of
the cystic and common duct is excised or
removed.
 Associated RHA injury (35%)

14. Class IV injury :
 involve damage to the right
hepatic duct (RHD), either
because this structure is
mistaken for the cystic duct, or
because it is injured during
dissection.
 Damage to Right hepatic artery
(60%) which is mistaken for
cystic artery.

15. Thank you …