Bile duct injury is an unavoidable complication following any laparoscopic or open cholecystectomy. Almost everyone goes through it. One must take care to avoid the BDI, and one must know what to do when it happens.

1. Dr. Keyur Bhatt
MS, FAIS, MRCS (UK), FACS (USA)
ASIA BOOK & INDIA BOOK Record holder for “Grand Master of laparoscopic
cholecystectomy”
LIMCA BOOK & INDIA BOOK Record holder “longest foreign body removal
from stomach”

2. Greetings from our teaam

3. Management of biliary
complications following
Cholecystectomy
02.02.2020

4. What every one thinks about a LC

5. What actually is LC

7. Type wise definitive management –
Our experience
Surgical Only surgical
endostentin
g
SIDS TYPE
ENDOSCOP
IC
HJ
Only
TTD
Total
Type I 114 0 114
Type II 37 0 37
Type III A 15 6 4 25
Type III B 23 23
Type III C 8 8
Type III D 2 2
Type IV 0 2 2
TOTAL 166 39 4 2 211

8. REVIEW
• Following LC , Biliary complication Incidence is
reported to be 0.7 as compared to 0.4 for OC. (almost 2
times)
• Why do injury happens
– A. anatomical variations
– A. Miss interpretation of
Anatomy 70%
– B. local pathology
– C. technical problems, (lack of 3d vision, tactile perception,
etc)
– D. learning curve, (inexperienced surgeon or over
confident surgeon(after 75-100 cases)

9. Some facts
Following LC – cystic duct
stump blow out most
common cause-
• Improper application of
clips, use of diathermy ,
energy source to divide CD
can lead to thermal injury
and necrosis of stump 
slippage of clip
• In bile duct injury laceration
/ lateral injuries caries less
risk than transaction or
circumferential injury as the
blood supply runs parallel to
CBD

10. Complications
• Biliary cirrhosis
• Recurrent cholangitis
• PHT
• DEATH mostly due to liver failure

11. Risk factors of poor outcome
• Biliary reconstruction in presence of
peritonitis
• Combined vascular and biliary injury
• Injury at or above the level of biliary
bifurcations
Independent significant risk factors of poor
outcome

12. Why to discuss
• Why do we need to classify injuries?
• Ans- to know outcome, severity, possible
management guidelines
• Bismuth
• Strasberg classification
• McMohan

13. JUST REVISE THE CLASSIFICATION

14. Strasberg A Cystic duct /minor biliary
duct injury from GB fosse

15. B- occlusion of part of biliary tree
(most commonly Rt sectoral duct)

16. C – Transaction without ligation of Rt
sectoral duct

17. D – lateral injury
(CHD injury is more commonly seen with LC) –
WHAT IS CALLED AS CLASSIC injury of LC

18. E- can be divided in Bismuth 1-5

19. McMohan 1995
• A – Cystic duct leak or leakage from aberrant
Hepatic ducts
• B – Major leak with/without concomitant
strictures
• C- Bile duct strictures without leaks
• D- Complete transaction of CBD with excision
of part of CBD

21. Clinical presentation of patient
1. ACUTE BILE DUCT INJURY DETECTED DURING
SURGERY
2. POST OP BILIARY FISTULA FROM DRAIN
(CONTROLLED) OR WOUND
3. BILOMA / BILIARY PERITONITIS
4. DELAYED PRESENTATION WITH BILIARY
STRICTURE FOLLOWING LC/OC.(Bismuth
types)

22. Our Data till 2018
Type of presentation Number of
patients
Percentage of
total
On table detected 13 6.16
Biloma 06 2.84
Controlled biliary fistula /drain 149 70.61
Biliary peritonitis infected 30 14.21
Delayed presentation with Biliary
stricture
13 6.16

23. 1. ACUTE BILE DUCT INJURY DETECTED
DURING SURGERY
• This carries the best chance of management
amongst all types of injury
• Prognosis is best if managed properly
• But this is only 25% of all BDI.

24. What to do?
• Who is experienced in the field
• Lap convert to open- to identify the
structures in HDL, & identify the severity of
injury
• Still unclear  stop dissection, put drainage,
come out.

25. What to do?
• Simple type D injuries are repaired by closure of the
defect using fine absorbable sutures over a T tube /
endo biliary stent and placement of a closed suction
drain in the vicinity of the repair.
• If identified less than 1/3
of circumference injury

26. What to do?
• Type D injuries that are thermal in origin or that
are complex are best repaired by
hepaticojejunostomy(HJ)
• Segment loss more than 1/3 circumference
injury—(expertise available) , injury bellow
confluence Without sepsis No vascular
compromise HJ
• BUT FOR HIGHER LESIONS AND INJURY ABOVE
THE BIFURCATION– ONLY DRAINAGE AND LATER
REPAIR.

27. What to do?
• Type C injury:
• Confirm first (IOC) and can be
simply ligated /over sewed (if
sectoral duct)
• If RHD drain / internal stenting
• Nearly impossible to reconstruct -
and should never be tried in
emergency without expertise

28. Clinical presentation of patient
1. ACUTE BILE DUCT INJURY DETECTED DURING
SURGERY
2. POST OP BILIARY FISTULA FROM DRAIN
(CONTROLLED), or WOUND
3. BILOMA / BILIARY PERITONITIS
4. DELAYED PRESENTATION WITH BILIARY
STRICTURE FOLLOWING LC/OC.(Bismuth
types)

29. Presentation
• Bile in drain
• Bile from wound
• We need to look @ this not the amount of
bile leakage
• With or without fever / sepsis / high TLC
• With or without Jaundice
• With or without associated Biloma

30. • Controlled fistula (no associated collection)
Non toxic patient MRCP (Typing of injury )
ERCP
• IF A,C, Selected D (no associated collection) 
STENTING OF CBD
• IF COMPLETE LIGATION OF CBD  WAIT FOR
6 WEEKS – OBSERVE THE OUTPUT – SOS PTBD
/ External Drainage – DELAYED HJ.

31. Clinical presentation of patient
1. ACUTE BILE DUCT INJURY DETECTED DURING
SURGERY
2. POST OP BILIARY FISTULA FROM DRAIN
(CONTROLLED), or WOUND
3. BILOMA / BILIARY PERITONITIS
4. DELAYED PRESENTATION WITH BILIARY
STRICTURE FOLLOWING LC/OC.(Bismuth
types)

32. • Presentation:
• NON SPECIFIC SIGNS
• Abdominal tenderness, discomfort,
generalized malaise and anorexia with or
without FEVER
• Investigations: Routine blood Ix +
• Noninvasive imaging (US/CT scan) is essential
to define Biloma

33. What next ?
• BILOMA  may require percutaneous or surgical
drainage (most essential)
• ERCP and percutaneous transhepatic
cholangiography (PTC) can provide an exact
anatomical diagnosis of bile duct leak, while at
the same time allowing for treatment of the leak
by appropriate decompression of the biliary tree
if needed.
• But prior to that bile needs to be taken out of
abdomen

34. Why ?
• Biliary tree is sterile most of the times so as the
Bilioma (even though they are post op) (except
pre op cholangitis)
• The moment sphenctorotomy is done and stent /
dye placed in CBD BACTERIA ENTERS THE
SYSTEM (after any ERCP bactibilia is 100%,
cholangitis may or may not happen)
• LEAKS FROM THE INJURY PARTSPREADS ALL
OVER THE ABDOMEN 
• BILOMA  BILIARY PERITONITIS

35. What next after drainage..
• In case of CBD stone removal with
sphincterotomy is treatment of choice.
• If there is no stone, then internal stenting with
or without sphincterotomy has shown to be
effective in treating bile leaks of Type A,C,D.

36. Cont…
• Endoscopic internal Stenting is currently
procedure of choice for treating bile duct leaks
(usually types A, C and D)
• 7 Fr and 10 Fr stents can be inserted without
sphincterotomy  Cessation of bile extravasation
in 70-95% of cases within a period of 1-7 days.
• PTC is usually reserved for instances when ERCP is
unsuccessful or in preparation for surgical repair

37. Clinical presentation of patient
1. ACUTE BILE DUCT INJURY DETECTED DURING
SURGERY
2. POST OP BILIARY FISTULA FROM DRAIN
(CONTROLLED), or WOUND
3. BILIOMA / BILIARY PERITONITIS
4. DELAYED PRESENTATION WITH BILIARY
STRICTURE FOLLOWING LC/OC.(Bismuth
types)

38. How to deal
• Patient usually presents with SOJ +/- Cholangitis
• If Cholangitis PTBD
• Always typing should be first - MRCP
• Most important factor in this type is timing of
surgery for the positive outcome
• Immediate post operative repair carries high risk
of complications rate.
• Late reconstruction after 6 weeks is rule of
THUMB.

39. Hepatico Jejunostomy

40. Summary
• BDI are rare complications of Cholecystectomies
LC or OC but they can devastate and individual by
turning him into a “biliary cripple” and most
ultimately die of liver failure.
• They often occur from errors of human
judgment and are thus preventable…
• Marriage of experience of OC &
vision/magnifications of LC should reduce the
incidence of such catastrophes.

41. SIDS Classification of BDI

47. Video

48. THANKS