Surgical approach

1. POST CHOLECYSTECTOMY
BILE DUCT INJURY
MANAGEMENT
Dr Sujan Shrestha
MCh, Second Year
GI surgery, TUTH

2. Management of bile duct injury detected intraoperatively
How frequent we recognize the injury intraoperatively?
A BDI is detected during laparoscopic cholecystectomy in only one-fourth to one-third of cases.
31 %
26 %
Lillemoe KD, Pitt HA, Cameron JL. Adv Surg. 1992.
Stewart L, Way LW.. HPB (Oxford). 2009
Rest is detected as
• Bile leak
• Obstructive jaundice

3. Management of bile duct injury detected intraoperatively
Intraoperative recognition
Bile during calots dissection
Gallbladder
• Greenish yellow
• Thick
• Viscid
Bile duct
• Golden yellow
• Thin
• Watery
Alarming signs
• Vertical location of divided cystic duct
• Difficult to take gallbladder away from hepatic hilum
• Third structure in calots triangle

4. Management of bile duct injury detected intraoperatively
Bile duct injury suspected or detected intraoperatively
Now what?
Immediate vs delayed repair
Advantages (few)
• Less inconvenience and morbidity
• Shorter hospital stay
• Less treatment cost
• Less inflammation and no sepsis
Disadvantages (many)
• Treatment failure rate and complications
• Overall treatment cost and hospital stay was
even higher for patient requiring second
surgery
• Second surgery more difficult
Iannelli A, Paineau J HPB (Oxford). 2013
Failure rate for immediate repair was 57.6%

5. Management of bile duct injury detected intraoperatively
Primary general surgeon vs HPB surgeon
Undilated duct
Guilt
Anxiety
Stress
In experience
77 intraoperative repairs performed in 15
hospitals in China (1997–2007)—24/35
(69%) repairs performed by a laparoscopic
surgeon failed vs. 7/42 (17%) repairs
performed by a specialist surgeon
Xu XD, Zhang YC. Am Surg. 2011
Perfect recipe for disaster

6. Management of bile duct injury detected intraoperatively
Possible algorithm
Intraoperative detection
Intraoperative cholangiogram
Intraoperative ultrasound
HPB surgeon ( primary)
HPB surgeon on call
NO
Laparoscopic lavage
Wide bore drain at least 2
Placement of omentum in calots area
Concept of drain now fix latter
Refer to specialist center
• Proper intraoperative details
• Video ( intraoperative if possible)
Yes
Immediate repair can be planned
Lap vs open

7. Management of bile duct injury detected intraoperatively
Subvesical Duct Injury
Bile seen in the gallbladder bed away from the Calot’s triangle
Size of the duct
Less than 3 mm More than equal to 3mm
Can be clipped or ligated Should be drained
Bilioenteric anastomosis
1 2

8. Management of bile duct injury detected intraoperatively
Common Bile Duct Injury
Clipped but not divided
Remove the clip
No bile leak
Post operative stenting if delayed leak or stricture
Remove the clip
Bile leak
Treat as lateral bile duct injury

9. Management of bile duct injury detected intraoperatively
Lateral Injury
An incomplete/ partial/ lateral BDI with involvement of less than one-fourth to one-
third of the circumference of the common bile duct
Repaired with fine delayed absorbable sutures
Without stent
With stent
• T tube
• Biliary stent passed across ampulla (same stent used for ERCP)

10. Management of bile duct injury detected intraoperatively
Complete Injury
Tissue loss
No
End to end repair
• With out stent (backed up by data from liver transplantation)
• T tube or internal biliary stent
Yes
Bilioenteric anastomosis
64 % failed repair
50 % failed repair
29 % failed repair
Iannelli A, HPB (Oxford). 2013
Xu XD,Am Surg. 2011
Csendes A, Hepato-Gastroenterology. 1994
Hepaticojejunostomy
63 % repair failed

11. Management of Bile Duct Injury Detected in the Post-
Operative Period
About 70-80 % of bile duct injury are recognized on post operative period.
May present as bile leak or benign biliary stricture
Early Postoperative Period
• External biliary fistula if drain placed
• Bile leak( biloma, biliary peritonitis, biliary ascites)(high index of suspicion)
Investigations
• Rule out sepsis
• USG,CECT
 location of collection
 Rule out associated vascular and nonvascular injuries
• MRCP (after stabilization of patient)
 Delineate anatomy
 Classify the injury
 Predict the natural course
 Guide to further intervention

12. Management of Bile Duct Injury Detected in the Post-
Operative Period
Initial Management
 The initial management of a BDI is primarily directed towards control of sepsis
and bile leak.
 The aims of management are
• Drain any intra-abdominal bile collection,
• Treat sepsis (peritoneal and biliary),
• Stop or reduce the ongoing bile leak,
• Convert the acute BDI into a controlled EBF.
Usg guided or CT guided drainage is enough is multiple cases
One or more drain is required in most cases
Relaparoscopy or relaparotomy is rarely required for diffuse peritonitis not amenable for PCD.

13. Management of Bile Duct Injury Detected in the Post-
Operative Period Cystic Duct Leak
• Residual/retained CBD stone
• Incomplete clipping (partial circumference or inadequate loose clipping)
• Hole in the cystic duct stump (caused by thermal injury or a sharp instrument).
TREATMENT
• ERCP and stone extraction and stenting
• ERCP and stenting
• ERCP and occlusion of cystic duct stump using glue

14. Early repair
Repair within 6 wks following primary surgery.
Advantages (few)
• Less inconvenience to patient
• Less morbidity of percutaneous and radiological intervention
Disadvantages(many)
• Bile ducts are inflamed, edematous and friable
• Difficult to identify ducts
• Suture will not hold
• Usually patient are sick to operate
• Associated biliovascular injury
• Technically difficult as ducts are collapsed
• More postoperative complications
• More failure rate
May be done
• For complete injury
• No associated vascular injury
• Ligated duct
• Dilated system
PCD - biliaryenteric anastomosis-hepatectomy – liver transplantation
Spectrum of treatment

15. Surgical Management of Benign Biliary
Stricture
Delayed repair
Bilioenteric anastomosis
Timing of repair
Immediate : within 72 hrs
Intermediate : 72 hrs to 6wks
Delayed : 6wks to 6 months
Late : after 6 months Appropriate patient: no sepsis, controlled EBF
Appropriate time: after 6wks
Appropriate surgeon: HPB surgeon
Best result
VK KAPOOR

16. Surgical Management of Benign Biliary
Stricture
Appropriate patient: no sepsis, controlled EBF
Appropriate time: after 6wks
Appropriate surgeon: HPB surgeon
Delineate anatomy of biliary stricture
MRCP PTBD VS PTBC
PTBD done for sole purpose of drainage
• Cholangitis (biliary system will be collapsed post drainage)
• High output EBF
PTBC (PERCUTANEOUS TRANSHEPATIC BILIARY CATHETERISATION)
• Done one day prior to definitive repair
• With purpose of preoperative or intraoperative cholangiogram
• With purpose of intraoperative detection of duct
• Possible transanastomotic stent
One or more catheter might
be required depending
upon anatomy of biliary
stricture
3 MANTRA

17. Surgical Management of Benign Biliary
Stricture Anatomy of biliary stricture
MRCP +- PTBD or PTBC

18. Surgical Management of Benign Biliary
Stricture BILIOENTERIC ANASTOMOSIS
Principle of bilioenteric anastomosis
• Well vascularized
• Tension free
• Mucosa to mucosa
• Widely patent
• Precisely constructed
• Most important all liver segment
should be drained
Cholangio vs hepato
jejunostomy
VK KAP0OR

19. Surgical Management of Benign Biliary
Stricture BILIOENTERIC ANASTOMOSIS
End to side Side to side
When ever possible
Difficult on rt or sectorial duct
Complete circumferential mobilization required
 Difficult
 Vascular compromise
Wide anastomosis not possible

20. Surgical Management of Benign Biliary
Stricture
General consideration
Hockey stick incision Kent retractor

21. Surgical Management of Benign Biliary
Stricture Adhesiolysis
Meticulous Adhesiolysis is mandatory
Usually recommended from rt to left direction
1 2
3

22. Surgical Management of Benign Biliary
Stricture Identification of ducts
• Fistulous tract leads to proximal duct
• Proximal part of internal fistula
• Looking for clips
• Preplaced PTBC
Palpation of duct
Intraoperative USG
Intraoperative cholangiogram
Saline stained with colored dye installation (aspiration using fine needle)

23. Surgical Management of Benign Biliary
Stricture Identification of ducts
ARTOPHY HYPERTROPHY ROTATION
1

24. Surgical Management of Benign Biliary
Stricture
Hilar plate take down
For exposure of hilum and left hepatic duct Usually for E1,2,3 injuries
1
2 3

25. Surgical Management of Benign Biliary
Stricture
Hilar plate take down continued to cystic plate
For proper exposure right main or segmental ducts
Partial resection of segment 4 and 5
Partial resection of liver tissue ant to rt portal pedicle
For E4 , E5 and B injuries

26. Surgical Management of Benign Biliary
Stricture For E1,2,3
SIDE TO SIDE END TO SIDE STEWART SIDE TO SIDE
EVEN FOR E1 AND E2 hilojejunostomy is preferred
• Wide duct
• Good vascularity

27. Surgical Management of Benign Biliary
Stricture For E4
WHEN DUCTS ARE CLOSE
A
B

28. Surgical Management of Benign Biliary
Stricture
For E4
DUCTS FAR AWAY
E5
END TO SIDE
SIDE TO SIDE

29. Surgical Management of Benign Biliary
Stricture
Transanastomotic stent vs no stent
Not mandatory in dilated duct
Used in nondilated duct (3mm or less)
Anastomosis in nondilated duct
Use 5-0 delayed absorbable sutures
Use magnification loop
All knot post or ant wall outside lumen
Use transanastomotic stent
TRICKS BY MASTERS FOR NON-DILATED DUCT

30. Surgical Management of Benign Biliary
Stricture
Bilio-Enteric Anastomosis
• Stoma size 2-3 cm
• Jejunotomy 2/3rd of size of proximal stoma
• Single layer interrupted absorbable sutures
• Blumgart Kelly technique (as per prof VKK)
1
2

31. Surgical Management of Benign Biliary
Stricture Bilio-Enteric Anastomosis
3
4

32. Surgical Management of Benign Biliary
Stricture
Bilio-Enteric Anastomosis
5
6

33. Surgical Management of Benign Biliary
Stricture HEPATECTOMY IN BILE DUCT INJURIES
Not uncommon
12 out of 55 BDI
18 out of 120
11 out of 800
10 out of 355
Alves A, Ann Surg. 2003.
Laurent A Ann Surg. 2008.
Mercado MA. Rev Gastroenterol Mex. 2010
Booij KA,, van Gulik TM. Dig Surg. 2013
Hepatectomy is challenging
• Dense adhesion in calot’s triangle
• Atrophy hypertrophy rotation of hilum
• Infected operative field
• Infected biliary tree

34. Indications
Surgical Management of Benign Biliary
Stricture HEPATECTOMY IN BILE DUCT INJURIES
• Complex E4, E5 injuries ( where safe anastomosis is not possible)
• Symptomatic atrophic segment (biliovascular injury)
Isolated Rt post segmental injury with symptomatic lobar atrophy

35. Surgical Management of Benign Biliary
Stricture Liver transplant in BDI
INDICATIONS
• BBS not treated timely developing secondary biliary cirrhosis and ESLD
• BBS with failed repeated surgery or nonsurgical management with
Repeated episodes of cholangitis
Intractable pruritis
Progressive jaundice
Poor quality of life
• Acute liver failure

36. Surgical Management of Benign Biliary
Stricture Liver transplant in BDI
Br J Surg. 2014 Jan
Liver transplantation for bile duct injury after open and laparoscopic cholecystectomy
P Parrilla Spanish Liver Transplantation Study Group
Patients with BDI after cholecystectomy who were on the waiting list for LT between January 1987 and
December 2010 were identified from LT centres in Spain.
27 patients
Emergency LT for acute liver failure was indicated in seven patients
Elective LT for secondary biliary cirrhosis after a failed hepaticojejunostomy was performed in 20
patients
The estimated 5-year overall survival rate was 68 per cent.

37. THANK YOU