This document provides guidance on the management of CBD injuries. It discusses: - Recognizing injuries during or after cholecystectomy and appropriate next steps like drain placement or referral. - Surgical repair approaches like end-to-end anastomosis or biliary enteric procedures depending on the type and location of injury. - Managing injuries presenting later as biliary strictures or leaks, often through staged approaches using external drainage first. - Techniques for different stricture types, including exposing healthy ducts proximally and creating mucosa-to-mucosa anastomoses to distal conduits.

1. Management of CBD injuries
Dr. Uttam Laudari
First Year Resident
01/31/2015

2. Recognized at time of cholecystectomy
• Experienced surgeon
• Its not immediately desperate
• always worth waiting for another opinion and technical
assistance
• Each failed repair is associated with some loss of bile duct
length

3. • No assistance
• Place drain to control any biliary leak and REFER

4. • ABANDON LAPARASCOPIC APPROACH
• RIGHT SUBCOSTAL/EXTENDED SUBCOSTAL AND CHEVRON
INCISION
• Operative cholangiography to dilineate anatomy and type of
injury

5. Aim
• Maintenance of ductal length below the hilus with out
scarifying tissue
• Avoidance of uncontrolled postoperative bile leak

6. • Small ducts injury
– difficult to repair
– Insert external drainage by placing tube proximally into the
bile duct and REFER then to repair which is likely to fail
Aim at maintaining length and preventing fistulation

7. Complete transection
• End to end repair over T- tube
– Transected ends should be apposed without tension
– Mobilization of duodenum and head of pancreas
– Single layer of interrupted absorbale suture with T tube brought
out of bile ducts away from anastomosis
– Silk suture- avoid- promotes inflammatory reaction and nidus
for stone formation
– Drawback- 50-60% stricture
– Roux eny HJ better for long term results and is recommended

8. Lateral duct wall injuries
• Small/ simple laceration
– repair with interrupted 4-0, 5-0 absorbable suture
– T- tube ??
• uncecessary
• Decompressed bile duct may exacerbate injury while placement

9. • Long lateral wall injuries
– Impossibe for transverse repair without compromising
lumen
– Direct repair over T- tube – future stenosis
• Use of –
– veins patch, cystic duct stump, pedicled flap of jejunum,
Roux loop of jejunum as serosal patch

10. • T- tube placed across the defect and its long limb led out
through roux loop and exteriorized through abdominal wall
cavity

11. Advantage-
• Bile duct maintained
• Jejunal serosa used to cover defect secured in place with fine
interrupted sutures to bile duct without attempting direct
approach to ragged edge of damaged duct
• T- tube causes bile decompression across jejunum so that
when it is removed any leaking bile will drain into the bowel
lumen rather abdominal cavity

12. Injury recognized in immediate postop
period
• Mode of presentation
– Bile drainage through wound
– Biliary peritonitis
– Progressive jaundice
– Or depends on the type of injury

13. • External biliary fistula
– Avoid early reoperation
– Investigate
– Nutrition
– Free from sepsis
– Fistulography- bilioenteric
communicationprolong drainage
spontaneous closure if no distal obstruction

14. • Severe lacerations or complete transections
• Biliary tree decompressed difficulty operation
• Adequate repair requires
– Exposed healthy bile duct mucosa within a sufficiently dilated proximal system
to allow precise anastomosis
• Decompressed bile ducts and inflamed
• Technically demanding, delayed approach most
appropriate– for spontaneous closure and time for
proximal systems dilatation

15. • high output biliary fistula for prolong time creation of
temporary internal fistulojejunostomy and definitve mgmt
later
• Or placement of endoscopic sphincterotomy to facilitate bile
drainage and decrease the fistula output.
• such procedures require 2-3 weeks time to intervene and by
that time most fistula close or decrease substantially

16. • Biliary peritonitis
– Bile drainage and controlling ongoing leak is primary
objective
– Percutaneous abscess drains, or percutaneous bilirary
catheters
– Definitive repair difficult as bile ducts are collapsed,
deeply bile stained and
– best delayed untill biliary leak completely controlled
and fully resuscitated

17. Injury presenting at interval after initial
operation
• Present as biliary strictures
• Principles
• Exposing healthy proximal bile ducts draining all areas
of liver
• Preparation of suitable segment of distal mucosa for
anastomosis
• Creation of mucosa to mucosa sutured anastomosis of
bile ducts to distal conduits

18. • Staged approach to stricture repair in the
presence of intrabdominal infection, portal
hypertension, and poor general condition
• External bile drainage
• Sepsis control
• Treating existing condition

19. Technical approach to biliary aproach
• End to end duct repair
– Excision of stricture with end to end anastomosis
– Establishing normal anatomical continuity and
drainage via intact sphincter of oddi
– 50-60% long term failure
– Limited role

20. Biliary Enteric repair procedures
• Procedure of choice in most cases
• Choledochoduodenostomy-
– Stricture of retropancreatic or immediate portion of CBD
• Side to side/end to side anastomosis
– Appropriate only in setting of dilated CBD
– Recurrent stricture high chance if created in decompressed
duct

21. • Stricture of common hepatic duct
• Difficult to manage, specially those involving biliary
confluence
• Almost always require Roux en Y HJ

22. • Striture Type I and II ( below the confluence)
– Direct anastomosis to hepatic duct stump
• Type III and Type IV
– Difficult to achieve good results
– Choice of surgical approach should be tailored tailored to
height and extent of lesion

23. • Type III and IV stricture
– Biliary enteric anastomosis to left hepatic duct provides
complete drainage of both left and right ductal system

24. Type III/IV
Division of falciform ligament
Freeing liver from adhesion
Starting dissection from Right subhepatic area
Mobilizing hepatic flexure of colon below and working upward
and medially
Mobilizing duodenum- may be adherent to undersurface of
liver and hilar structures particularly in are of stricture

25. • Identifying duct below the strictures are unnecessary, as distal
duct generally cannot be used for anastomosis
• Also extensive dissection to free it risks injury to heptic artery
and portal vein
Identification of bile duct proximal to stricure

26. • In generally much easier and safer to expose the left hepatic duct by
lowering the hilar plate at base of segment IV ( quadrate lobe)
• As this area has not been disturbed by previous surgeries and is likely to
relatively free from adhesions
• This maneuver delivers left hepatic duct and biliary confluence from under
surface of liver and makes identification of stricutred area much easier

30. • Adhesions posterior to damaged duct may be
dense, extensive dissection in this situation
risks injury to underlying portal vein

31. • Ligamentum teres approach
• Rarely used procedure when there is dense adhesions,
bleeding or large overhanging quadrate lobe
• Sometime extra hepatic length of left hepatic duct may be
relatively short and oblique making other approach difficult

34. Mucosal graft procedures of Smith
• Introduced for treating high strictures
• Where hilar dissection is impossible and proximal ducts
cannot be delivered for mucosa to mucosa anastomosis
• Utilizes trashepatic tube to draw jejunal mucosa high up into
the hepatic ducts and allowing apposition
• Hepatic tubes left in place for 2-6 month

36. • Drawbacks
• Dome of jejunal mucosa drains into the hepatic ducts which
blocks secondary intrahepatic ducts and isolating segments of
liver tissue
• Mucosa slips postoperatively and jejunal loop detaches
• Recurrent stricture at previous mucosal grafts

37. Liver split and liver resection
• To expose the bile duct for repair Hepatotomy
• By opening umbilical fissure for access to segment III or
extending subhepatic approach to expose origin of RHD
• Upward mobilization of quadrate lobe and opening the
umbilical fissure facilitates access for type IV strictures when
access to RHD is difficult

38. • Longmire approach
– Intrahepatic hepaticojejunostomy
– Resection of left lateral segment (II and III)
– and anastomosis to ducts exposed on the cut surface of
liver.
– Difficult and dangerous procedure (hemorrhage)
– Limited to case with left lobe hypertrophy

40. Combined modalities approach-
• Most strictures are managed by modalities described above
• With risk of recurrent strictures or stone formation
• High hepaticojejunostomy over
trans-jejunal tube brought exterior
across the blind end of roux limb

41. • Defunctionalized roux limb left long and end is secured subcutaneously or
subperitoneally
• This allows easy access for cholangiography, cholangioscopy, dilatation or
stone removal
• Also the blind end of roux-en-Y limb may be re-accessed by percutaneous
puncture under fluoroscopic guidance
or small incision under local anesthesia
for late diagnostic and
therapeutic procedures long
after transjejunal tube has been removed.

42. Nonoperative Approach
• Percutaneous balloon dilatation
– Multiple admissions
– Repeated interventions
– Overall costs and morbidity not much difference with operative
procedures
• Operative procedure more effective and provides more
durable relief
• Preferable in patients not tolerable to operations

43. References
• Surgery of Liver and Biliary tract- L.H Blumgart
• Sabiston Text book of surgery