This document provides information on the diagnosis and management of biliary tract injuries. It begins with an overview of biliary anatomy and classifications of injuries. Key points include: - Biliary injuries can occur during cholecystectomy and liver transplantation. Common mechanisms involve misidentifying structures and thermal or mechanical damage. - Injuries are classified using systems like Bismuth and Strasberg to determine severity and guide treatment. - Diagnosis may involve intraoperative identification of bile leaks or postoperative imaging like MRCP or ERCP. Transhepatic cholangiography provides the best view of anatomy. - Treatment depends on injury type but may include drainage, stenting, resection, or bilioenter

1. lesiones de vías
biliares
Diagnostic
Humberto Juárez Rosario
medico residente cirugía general

2. IntroducciónAnatomía
Juicio, técnica y atención a los detalles
Incidencia:
• Abierta 0.1 a 0.2 %
• Laparoscopica 0.4 a 0.6 %
• 750 000 Colecistectomias laparoscopicas
• Trauma hepatico 0.5%
Iatrogenic Biliary Injuries: Classification, Identification, and Management Kenneth J. McPartland, MDa,b, James J.
Pomposelli, MD, PhD Clin N Am 88 (2008) 1329–1343

3. Anatomía
Lesiones de vias Biliares. Miguel Mercado 2005

4. Anatomía
Lesiones de vias Biliares. Miguel Mercado. 2005

5. Anatomía
Lesiones de vias Biliares. Miguel Mercado. 2005

6. %20Liver_fichiers/l
oadBinaryCA6XK5IZ.
jpg

7. Anatomia

8. Impacto
Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND &
BOBBY TINGSTEDT HPB, 2008; 10: 416-419
Costos segun el tipo de lesión

9. Transplante
Hepático
10 a 12%
fugas biliares
estrecheses en la anastomosis y fuera de ella
mas prevalencia en receptores pediatricos

10. Fisiopatología

11. Factores de riesgo
colecistitis
Adherencias del cistico y coledoco
hemorragia
Variantes anatomicas

12. Factores de Riesgo
Factor OR
sexo masculino 1.92
hospital escuela 2.16
Pancreatitis 2.5
Colangiografia 0.5
Fletcher et al. annals of surgery 1999

13. Mecanismos
Mala interpretacion de las estructuras anatomicas
(97%)
errores tecnicos (3%)
Incapacidad o resistencia de realizar colangiografia
excesiva retraccion cefalica del fondo
Poca retraccion lateral del infindubulo
Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006
Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and
Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No.
4, 460–469

14. Mecanismos
Uso excesivo del cauterio
excesiva retraccion lateral del infindibulo
radical derecho de insercion baja
Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006
Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and
Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No.
4, 460–469

15. Esquema mental
Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and
Cognitive Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237,
No. 4, 460–469

16. Visiones heuristica
Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive
Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
■ Si no consigues entender un problema, dibuja un esquema.
■ Si no encuentras la solució n, haz como si ya la tuvieras y mira qué
puedes deducir de ella (razonando a la inversa).
■ Si el problema es abstracto, prueba a examinar un ejemplo concreto.

17. Mecanismos - Trasplante
Trombosis de la arteria hepatica
lesion durante la preservacion
barro biliar

18. Prevencion

19. Prevencion
Maniobra critica
uso de lente angulado
mantenerse cerca a la vesicula
Minimizar el uso del cauterio
Ver las puntas de los clips
colangiografia transoperatoria?¿

20. Prevencion
diseccion del tejido sobre el cistico y el infindibulo
uso de mas de ocho clips

21. Maniobra critica

22. Prevencion
Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?
Chandika A. H. Liyanage Æ Yoshihiko
colangiografia por el dreanje nasobiliar

23. tecnicas visualizar estructuras
Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future
patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011

24. colangiografia fluorescenia
infra-roja
Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of
current and future patient safety interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs

25. Clasificaciones

26. Clasificacion de Bismuth

27. Clasificación de
Strasberg

28. Clasificacion de Stewart-way
Class I refers to the incomplete sectionof
bile duct with no loss of tissue. It has a
prevalence rate of 7%. The first mechanism of injury
is a misleading recognition of the common hepatic
duct with the cystic duct but is rectified and results in
only a small loss of tissue with no complete section of
the bile duct. The second mecha- nism refers to the
lateral injury of the common hepatic duct which
results from the cystic duct opening extension during
cholangiography. The former represents 72% and the
latter 28% of class I cases.
Class I refers to the incomplete sectionof
bile duct with no loss of tissue. It has a
prevalence rate of 7%. The first mechanism of injury
is a misleading recognition of the common hepatic
duct with the cystic duct but is rectified and results in
only a small loss of tissue with no complete section of
the bile duct. The second mecha- nism refers to the
lateral injury of the common hepatic duct which
results from the cystic duct opening extension during
cholangiography. The former represents 72% and the
latter 28% of class I cases.
Class II is a lateral injury of the common hepatic duct
that leads to stenosis or bile leak. It is the
consequence of thermal damage and clamping the
duct with surgical
staples. It has a prevalence of 2% with a concomitant
he- patic artery injury in 18% of cases. T-tube related
injuries are included within this class.
Class II is a lateral injury of the common hepatic duct
that leads to stenosis or bile leak. It is the
consequence of thermal damage and clamping the
duct with surgical
staples. It has a prevalence of 2% with a concomitant
he- patic artery injury in 18% of cases. T-tube related
injuries are included within this class.
Class III is the most common (61% of cases) and rep-
resents the complete section of the common hepatic
duct. It is subdivided in to type IIIa, remnant
common hepatic duct; type IIIb, section at the
confluence; type IIIc, loss of confluence; and type
IIId, injuries higher than confluence with section of
secondary bile ducts. It occurs when the common
hepatic duct is confounded with the cystic duct,
leading to a complete section of the common hepatic
duct when resecting the gallbladder. A concomitant
injury of right hepatic artery occurs in 27% of cases
Class III is the most common (61% of cases) and rep-
resents the complete section of the common hepatic
duct. It is subdivided in to type IIIa, remnant
common hepatic duct; type IIIb, section at the
confluence; type IIIc, loss of confluence; and type
IIId, injuries higher than confluence with section of
secondary bile ducts. It occurs when the common
hepatic duct is confounded with the cystic duct,
leading to a complete section of the common hepatic
duct when resecting the gallbladder. A concomitant
injury of right hepatic artery occurs in 27% of cases
Class IV describes the right (68%) and accessory right
(28%) hepatic duct injuries with concomitant injury of
the right hepatic artery (60%). Occasionally it includes
the common hepatic duct injury at the confluence
(4%) besides the accessory right hepatic duct lesion.
Class IV has a prevalence of 10%[11,12].
Class IV describes the right (68%) and accessory right
(28%) hepatic duct injuries with concomitant injury of
the right hepatic artery (60%). Occasionally it includes
the common hepatic duct injury at the confluence
(4%) besides the accessory right hepatic duct lesion.
Class IV has a prevalence of 10%[11,12].

29. Diagnostico

30. Diagnostico
Transoperatorio
salida de bilis del higado o porta hepatis
observar un segundo conducto o arteria cistica
USG Doppler estrechez de la via biliar
Salida de bilis de una estructura tubular u otro sitio
distinto a la vesicula
ecause 12% to 32% of patients who have laparoscopic
cholecystectomy– associated bile duct injury have a
concomitant arterial injury and vascular injury
significantly increases morbidity and mortality and may
increase the incidence of later stricture formation
ecause 12% to 32% of patients who have laparoscopic
cholecystectomy– associated bile duct injury have a
concomitant arterial injury and vascular injury
significantly increases morbidity and mortality and may
increase the incidence of later stricture formation

31. Diagnostico Trans-
operatorio
Tejido fibroso en la el lecho vesicular
linfaticos rodeando al conducto cistico
conducto cistico que no se puede ligar
un cistico que se va sin interrupcion hasta el duodeno
75% inadvertidas
22% tuvieron protocolos que expusieron la dificultad
Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive
Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469

32. Porcentaje de deteccion
intraoperatoria
Bile Duct Injury during Laparoscopic Cholecystectomy : Risk Factors, Mechanisms, Type, Severity and Immediate Detection
J.-Fr. Gigot Acta chir belg, 2003, 103, 154-160

33. Diagnostico Post-
Operatorio
Fuga Biliar
Obstruccion
biliar
Cuadro
Clinico
Nauseas, vomitos,
peritonitis
Colangitis
Patron
bilirrubina
Mixto Directo

34. errores en
diagnostico
Ileo, distension y dolor abdominal
Falla en reconocer el drenaje bilioso persistente
Regreso al cuarto de urgencia
No realizar colangiografia previo a la LPE
no encontrar el sitio de lesion
Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition

35. diagnostico y fines
conocer la anatomia
reestablecer la comunicacion bilio-enterica

36. CPRE
Fuga del muñon del cistico vs lesion
intra/extrehepatica
Coledocolitiasis
Limitacion en oclusiones y ligaduras
e missed on ERCP (6). Aberrant right posterior
segmental duct injuries are often suspected in the
setting of clinical or imaging evidence of a bile leak
(perihepatic fluid collection on postcholecystectomy
cross-sectional imaging or copious bil- ious output
from surgical drains) but “normal” ERCP
e missed on ERCP (6). Aberrant right posterior
segmental duct injuries are often suspected in the
setting of clinical or imaging evidence of a bile leak
(perihepatic fluid collection on postcholecystectomy
cross-sectional imaging or copious bil- ious output
from surgical drains) but “normal” ERCP

37. Colangiografía Transhepática
identifacion de la anatomia
busqueda de fugas, estrecheces
tutor y drenaje
Cholangiography is used to distinguish between a
transected duct, a completely occluded duct, and a
duct that has been partially obstructed.
Cholangiography is used to distinguish between a
transected duct, a completely occluded duct, and a
duct that has been partially obstructed.
Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries Nicholas Fidelman, MD, Robert K.
Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol 2011;10.1016/j.jvir.2011.02.007

38. Colangiografía Transhepática
Deteccion del punto lesion 85%
100% 92% 55% 83% 82%

39. Resonancia
magnetica
Se ve todo el arbol biliar
desventaja costo
no terapeutica

40. Ultrasonido
busqueda de colecciones
dilatacion de via biliar

41. Tomografía Computada
deteccion de Colecciones
patencia de la circulación
Planeamiento de Drenaje de Colecciones

42. HIDA
Sospecha de fuga
No detecta el sitio

43. algoritmo Diagnostico
Sospecha de Lesión
CPRE
Fuga
Lesión Parcial
Seccion
CPTHProtesis
Centelleo Hepatobiliar
negativa

44. Tratamiento

45. Tratamiento
Reduccion de la presion
distal
Endoscopico o Tubo en T
fuga de alto y bajo grado
Strasberg A
Evaluation and Treatment of Biliary Leaks after Gastrointestinal Surgery
Gary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI 10.1007/s11605-011-1513

46. Tratamiento
Manejo Conservador
Casos refractarios: drenaje
percutaneo resecciones
segmentarios
Strasberg b
Segmentary bile duct occlusion is the etiological factor
in this type of injury. If mild pain and elevation of
liver function tests are present with no clinical
impairment, conservative management is followed.
The presence of moderate and severe cholangitis
makes the drainage of the occluded liver segment
necessary.
Segmentary bile duct occlusion is the etiological factor
in this type of injury. If mild pain and elevation of
liver function tests are present with no clinical
impairment, conservative management is followed.
The presence of moderate and severe cholangitis
makes the drainage of the occluded liver segment
necessary.

47. Tratamiento de
fugas
Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech
Gastrointest Endosc 8:81-91 2006

48. Seguimientos estenosis
Postoperative Bile Duct Injuries Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech
Gastrointest Endosc 8:81-91 2006

49. Tratamiento
Manejo Conservador
Drenajes externos
Hepatectomia
Derivacion biliodigestiva/
Drenaje percutaneo
Strasberg c
As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal
stump is not detected and oc- cluded, with an unnoticed bile leak as a
consequence. No continuity exists with the rest of the bile duct system, leaving
endoscopy out of the therapeutic options.
Subhepatic collections are frequent in the postopera- tive setting. These must be
drained in order to avoid bili- ary peritonitis and septic shock.
It is common that the bile leak is occluded spontane- ously with no other
intervention maintaining a controlled bile leak through external drains. If this does
not happen, therapeutic options are the same that Strasberg B injury, biliodigestive
derivation to segmentary ducts (also with poor long term prognosis), percutaneous
drainage and hepatectomy.
As in Strasberg B injury, an accessory right duct is sec- tioned but the proximal
stump is not detected and oc- cluded, with an unnoticed bile leak as a
consequence. No continuity exists with the rest of the bile duct system, leaving
endoscopy out of the therapeutic options.
Subhepatic collections are frequent in the postopera- tive setting. These must be
drained in order to avoid bili- ary peritonitis and septic shock.
It is common that the bile leak is occluded spontane- ously with no other
intervention maintaining a controlled bile leak through external drains. If this does
not happen, therapeutic options are the same that Strasberg B injury, biliodigestive
derivation to segmentary ducts (also with poor long term prognosis), percutaneous
drainage and hepatectomy.

50. Tratamiento
Rafia Primaria - Drenaje
percutanea - endoscopia
con Esfinterotomia/Protesis
Desvacularización
Tratamiento quirúrgico
ultima opción
Strasberg D
In the setting of a devascularized duct, even if small
5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week
with concomitant bile collections. Management of these cases requires a mul- tidisciplinary
approach with endoscopy and radiological- guided drainage as the first therapeutic options.
Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration
of a Strasberg D to E in- jury has taken place.
In the setting of a devascularized duct, even if small
5-0 absorbable stitches are used, a bile leak will develop during the first postoperative week
with concomitant bile collections. Management of these cases requires a mul- tidisciplinary
approach with endoscopy and radiological- guided drainage as the first therapeutic options.
Surgery is the last resource of treatment when a loss of bile duct tissue is present and migration
of a Strasberg D to E in- jury has taken place.

51. Tratamiento
Hepato-yeyunostomia
Strasberg e

52. dilataciones/Protesis vs Cirugia
cirugia Promedio
(Rango)
Dilataciones
Promedio
(Rango)
Exitos temprano ( 0 a 4
años) % 89 (81-98) 74 (27-95)
Exitos Tardio( > 4 años)
% 85 (74-99) 55
Dias de Tratamiento
(dias) 14 (7-27) 365 ( 146-550)
Hospitalización (dias) 14 (7-27) 24 (10-38)
Morbilidad % 19 ( 4-39) 28 (5-72)
Mortalidad % 1.6 (0-9) 1.3 (0-22)
Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd
edition

53. Cirugía

54. Hepato-yeyunostomia en y
de roux
•parte anterior de la placa
•extension al radical izquierdo
•resecciones parciales
segmento IV

55. Segmento IV

56. Hepp-couinaud

57. Hepp-couinaud

58. Hepp-couinaud

59. Hepp-couinaud

60. Hepp-couinaud
The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993

61. Claves anatomicas
Circulacion 3 y 9 horas
60% de la circulacion tiene
una direccion cefalocaudal
las anastomosis altas no
dependen de la arteria
hepatica derecha

62. Perlas del exitoerradicar la sepsis e
inflamacion
usar tejido viable
una capa mucosa-mucosa
monofilamento absorbible
sin tension
protesis no son mandatarias
cirujano con experiencia

63. Resumen del Cohorte de los tres
periodos
Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J

64. Recomendaciones
Lesion de via biliar laparoscopica
No convertir
dejar drenajes y referir
Hacer hemostasia
anastomosis Amplias
diferir procedimientos en casos de sepsis o falla
organica multipleClassification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011
April 27; 3(4): 43-48

65. recomendaciones
Centro terceriario
buscar ayuda
convertir
establecer el daño
Colangiografia

66. ¿cuando operamos?
Durante el evento, si la realiza un cirujano
experimentado
Estabilizar, drenajes y Referir

67. Reparacion temprana vs Tardia
No hay estudios aleatorizados
strasberg recomienda esperar 12 semanas*
Mercado no hubo diferencias entre el manejo
temprano y tardio (75 pacientes)
*Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of
biliary injuries having an isolated right-sided component. J Gastrointest Surg 5: 266–274

68. Cirugía
Hepatectomía
Daño irreversible del radical
Daño de la arteria Hepatica
Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April
27; 3(4): 43-48

69. Trasplante
cirrosis biliar secundaria
no se puede reconstruir

70. Pronostico

71. Contribución de los tratamientos al periodo
de enfermedad
Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd
edition

72. Pronostico
43 % de morbilidad luego de una reconstruccion
6 a 22% desarrollan enfermedad hepatica cronica
1.7 a 9% de mortalidad
Dilataciones y Stents
33% de las lesiones proximales a confluencia
desarrollan estrecheces
90% de éxito

73. The Good Surgeon believes what he sees, The Bad Surgeon sees wha
he believes.
Richard I Cook Cognitive Technologies Laboratory Chicago

74. Bibliografia
1. Iatrogenic bile duct injury-a cost analysis ROLAND ANDERSSON, KARIN ERIKSSON, PER-JONAS BLIND &BOBBY TINGSTEDT HPB,
2008; 10: 416-419
2. Prevention of Biliary Leaks. Nathaniel J. SopeJ Gastrointest Surg (2011) 15:1005–1006r
3. Accuracy of Percutaneous Transhepatic Cholangiography in Predicting the Location and Nature of Major Bile Duct Injuries
Nicholas Fidelman, MD, Robert K. Kerlan, Jr., MD, Jeanne M. LaBerge, MD, and Roy L. Gordon, MDJ Vasc Interv Radiol
2011;10.1016/j.jvir.2011.02.00
4. Evaluation and Treatment of Biliary Leaks after Gastrointestinal SurgeryGary C. Vitale & Brian R. DavisJ Gastrointest Surg DOI
10.1007/s11605-011-1513
5. Classification and management of bile duct injuries Miguel Angel Mercado, Ismael Domínguez J Gastrointest Surg 2011 April 27;
3(4): 43-4
6. Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd editio
7. Strasberg SM, Picus DD, Drebin JA (2001) Results of a new strategy for reconstruction of biliary injuries having an isolated right-sided
component. J Gastrointest Surg 5: 266–274

75. Bibliografia
9. Bile Duct Injuries in the Era of Laparoscopic Cholecystectomies Yuhsin V. Wu, MDa, David C. Linehan, MDb,* Clin N Am 90
(2010) 787–802
• Causes and Prevention of Laparoscopic Bile Duct Injuries Analysis of 252 Cases From a Human Factors and Cognitive
Psychology PerspectiveLawrence W. Way, MD,* Lygia Stewart, MD ANNALS OF SURGERY Vol. 237, No. 4, 460–469
• Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?
• Chandika A. H. Liyanage Æ Yoshihiko J Hepatobiliary Pancreat Surg (2009) 16:458–462 Postoperative Bile Duct Injuries
Kourosh F. Ghassemi, MD, and Janak N. Shah, MDTech Gastrointest Endosc 8:81-91 2006
• Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety
interventions K. Tim Buddingh • Vincent B. Nieuwenhuijs Surgical Endoscopy 2011
• The Hepp-Couinaud Approachto StricturesoftheBileDucts AlbertusMyburgh. Annals of Surgery Vol 218 No 5 1993
• Lesiones de vias Biliares. Miguel Mercado. 2005
• Surgical manajement of hepatobiliary and pancreatic disorders. L bumgart 2nd edition