Bile Duct Injury

COMPLICATIONS ARE PART OF LIFE

Incidence: 0.2% Incidence: 100%

BETTER AVOIDED THAN MANAGED

Bile duct injury – a major complication
of cholecystectomy

Better avoided than managed

 Incidence of Bile Duct Injury

• Open cholecystectomy: 0 – 0.4%

• Lap cholecystectomy: 0.3 – 0.6%

• 85% injury occur during lap. attempt

• 15% injury occur after conversion

• Incidence of BDI highest in ‘Mini Cholecystectomy’

• Mortality after open cholecystectomy: 0.17%

 Bile Duct Injuries

• 15% of injuries are recognized on table

• Majority - present in early post-op period

• Good number – present late –

• Sepsis

• Jaundice
 Special Features of Lap BDI

• Present early
• High injuries (Bismuth -2,3,4)
• Thermal injury
• Often presents with biliary fistula which is
difficult to close
• Majority occur during “Simple Cholecystectomy”
• 28% occur during acute cases which comprise only
10% of all cholecystectomies

Journ of Laproendos & adv surg tech 2001; 11(4):187-191

 Special Features of Lap BDI

Often Associated with Vs. injury

50% of Type E injuries are
associated with Vs. injuries
Injured Rt. Hepatic Art
Higher the injury, more chance
of RHA injury
 If associated RHA injury, chances
of good repair only if stump based
on LHA
Results of repair are better with
delayed repair Anastomotic
Hilar plexus
 Stump matures between Rt and
Lt Hepatic art.
 Level of ischemia is evident Axial branches
 BDI in Open Cholecystectomy

• 10% present in 1st week

• 70% present after 6 months

• Commonest – Type B & Type D  partial

ligature of CBD
 Laparoscopic Biliary Injuries
Strasberg’s Classification

A B C D

Biliary leak from

Biliary leak from a minor duct, not
duct still in continuity with Occlusion of a part of communicating with
main duct biliary tree Lateral injury
main ductal system
E1 to E5 – Bismuth Classification
E1 E2 E3 E4 E5
CHD CHD

> 2 CMS. < 2 CMS.

Lap BDI are higher injuries mostly Bismuth 2!

 A BDI becomes a Complex BDI when…..

• Type E2 and higher injury

• Previous failed repair

• L/C  87.5% of complete
• Associated Vs. injury transection are complex

• Cirrhosis • O/C  72% are complex

• Portal HTN

• 25-35% of BDIs – complex injuries

 Management of BDI
Depends upon
• Surgeon’s experience
• Extent of injury
• Detection of Injury
 Immediate
 Delayed

Golden Rule
• Safety of the patient – DON’T COMPROMISE
• Principles of Conv. Gen. Surgery – DON’T COMPROMISE
• Length of available bile duct – DON’T COMPROMISE
• Low threshold for conversion
• Don’t invent a new operation
 Recognition of BDI

Per Operative Post Operative Very late

presentation
Detection on table
Stricture
around 15 - 30%
Injuries Recognised on Table
 Type A
Type A Injury
Commonest Injury- (51.9%)

• Biliary leak from minor duct

• Still in continuity with CBD.
• Cause
• Inadequate closure of cystic duct
• Scissoring of clip
• Clip on a duct with stone
• Improper size
Management options
• Friable tissue
• Large duct • Proper clipping with
• Sequential clipping appropriate size
• Mis-identification of Duct of Luschka • Ligature
• Liver bed dissection in deeper plane • Endoloop
 Type A
Type A Injury

• Biliary leak from minor duct

• Still in continuity with CBD.

• Cause
• Inadequate closure of cystic
duct
• Scissoring of clip
• Clip on a duct with stone Management options
• Improper size • Suture close
• Friable tissue
• Drain
• Large duct
• Sequential clipping • If persists – ERCP with
• Mis-identification of Duct of stenting
Luschka
 Type B Injury Type C Injury
Type B Type C

• Occlusion of a part of biliary tree Biliary leak from duct, not

• Never detected on table communicating with main ductal
system
Causes
• Misidentification of anatomy

• Injudicious use of diathermy / clip for bleeding

• Too deep dissection in liver bed
 Type B & C Injury - Causes
Abnormal Anatomy

Cystic duct draining

into Aberrant RHD
 Type B & C Injury - Causes
Abnormal Anatomy

Aberrant duct
draining into GB
 Type B & C Injury - Causes
Abnormal Anatomy

Aberrant RHD with

low insertion
Type C
Management Type C injury

Biliary leak from duct

Not communicating with CBD.
Repair difficult
Management
POC through Cystic / injured duct
don’t divide any structure before POC
• Duct small (less than 3mm) – Ligate both ends.
• Larger duct – Repair over T – Tube
– Roux – en – Y
• Drain proximal end  Refer, as delayed approach may be more
appropriate
CONVERT IF NEED BE
Type D Type D

Management options
• Cause
• Small hole – suture close
• Thermal • <50% - repair + T-tube + Drain
• Mirrizi Type I & II • Avulsion of cystic duct – Repair + T-tube
• Partial clipping of CBD • >50% - Roux-en-Y
• Large longitudinal defect – Roux-en-Y
lateral serosal patch
Type D Management Type D injury

Lateral Injury

Management options
• Cause
• Thermal • Small hole – suture close
• Laceration during • <50% - repair + T-tube + Drain
dissection • Avulsion of cystic duct – Repair + T-tube
• Mirrizi Type I & II • >50% - Roux-en-Y
• Partial clipping of CBD • Large longitudinal defect – Roux-en-Y
lateral serosal patch
Type D Management Type D injury

Management options
• Cause
• Small hole – suture close
• Thermal • <50% - repair + T-tube + Drain
• Mirrizi Type I & II • Avulsion of cystic duct – Repair + T-tube
• Partial clipping of CBD • >50% - Roux-en-Y
• Large longitudinal defect – Roux-en-Y
lateral serosal patch
 Type E - Complete Transections
- the most dreaded
• Cause
• Wrong direction of
traction
 Type E - Complete Transections
- the most dreaded
• Cause
• Abnormal anatomy
• RHD draining into
cystic duct
• Short cystic duct
 Type E - Complete Transections
- the most dreaded
• Cause
• Dissection of cystic duct-
CBD junction rather than
cystic duct-infundibular
junction
 Type E - Complete Transections
- the most dreaded
• Cause

• Misidentification of CHD /
CBD as Cystic duct
 Type E - Complete Transections
- the most dreaded
• Cause

• Mirrizi and Scarring

 Type E - Complete Transections
- the most dreaded
• Other Causes

• Intra-op bleeding – clip & diathermy

• Fat in calot’s triangle

• Inadequate access

• Aggravation of injury – non performance of POC

 Typical sequence of Type E injuries

•A- Normal Anatomy

•B- CHD Misidentified as Cystic duct A B
•C- Complete transection of CBD with
loss of segment + Injury Rt.
Hepatic Artery
•D- Hepatic artery clipped ~ Vs injury
Occurs in 50% of cases

C D
Possible sites and mechanism
Type E injuries
THE FINAL COMMON PATHWAY OF
MOST INJURIES IS EITHER
TECHNICAL ERROR OR
MISINTERPRETATION OF
ANATOMY
L H Blumgart
Management Type E Injury
 Repair in Type E injury

• Only Repair advocated is

• Nothing less than a good bilio-enteric
anastomosis in the form of Roux en Y
Hepatico jejunostomy

• Repair over T-tube with end to end anastomosis -

ends up in stricture (>70%)
May be advocated only in cases of low
injury without loss of segment
 Criteria for good anastomosis

• Non scarred/non ischemic /non edematous

duct preferably extension into LHD as:
• LHD has a longer extra hepatic length
• stump survives on Left hepatic art
• Good sized stoma
• Tension free Roux loop
• Monofilament 5-0 suture
 Injury Recognized On Table
• Seek help
• More than 83% of repair performed by primary
surgeon yield poor result
• Nearly 100% secondary repair performed by
primary surgeon -- fail
• Don’t overestimate
• Always do POC –Detect extent of injury
Compromise on this may aggravate injury
• No duct to duct anastomosis (ischemia 
stricture)
• No hepatico-duodenostomy
• Stricture
• Dysfunction of anastomosis
• Food  obstruction  repeated cholangitis
 Injury Recognized on table
POC

No flow in prox duct Leak

Obstruction
Clip?

Accessory duct / Segmental duct CHD/CBD injury

If < 3 mm  Ligate Immediate repair or
If > 3-4 mm (Likely to drain multiple Controlled fistula
segments repair.

Once leak seen  no tissue to be divided unless POC is done

 Conclusion
• Repair only if primary surgeon is experienced

• Assess the severity

• Try to maintain the length of CBD / CHD stump

• Remember
• Injury tends to advance proximally
• Every failed repair further shortens the length & converts it into complex BDI
• Delayed repair may be a better option at times as the stump matures

• Only Roux en Y-hepatico-jejunostomy

• If surgeon is inexperienced
• Drain the hepatic duct
• establish a controlled biliary fistula
BDI presenting in early
Post – Op period
 Early Post-op Recognition of BDI

• 3 – 31 days (Avg.: 10 days)

• Shoulder pain: 87%
• Vomiting: 46%
• Jaundice: 36%
• Leak: 28%
• Fever: 24%
• Intra abd. Abscess: 9%
• Peritonitis: 8%
• Deranged LFT
• High ALP
• S.Bil not more than 3
 Injury could be

• Complete obstruction
• Progressive obstructive jaundice
• Deranged LFT – evident from Day 2 / 3

• Leak
• Fistula – evident if drain present
• Bilioma
• Biliary peritonitis
• Sepsis
• Without sepsis
 Cardinal Rule in management
• Do not rush for early repair
• Control Sepsis
• Control leak
• Abdominal Drains
• Multiple PTBD catheter
• Discourage prolong abdominal drains – endangers intestinal fistula
replace by Per cut. Trans hepatic drains

• Delayed repair (hepatico-jejunostomy)

• Ductal system is dilated
• Stump matures
• Level of ischemia is evident
 Actions to be Taken – Step I

• USG
• Leak - Collection
• Obstruction – dilated IHBR
• May demonstrate level of obstruction

• CT
• Collection (smaller collection may be missed
by USG)
• Obstruction – level
• Nature & extent of injury
• Vascular injury
 Actions to be Taken – Step II
USG / CT guided
aspiration with pigtail

Small large collections Multiple

collection or loculi
responding Biliary
peritonitis

Re-laparoscopy /
laparotomy  peritoneal
toileting & drainage
 Actions to be Taken – Step III
(After control of sepsis)

• MRCP / Fistulogram – if drain is present

• Correct diagnosis

• Type & extent of injury

Strasberg’s algorithm for repair

Classify Injury

Sepsis control

Drainage of all segments

Reassessment of injury

Patient preparation

Definitive repair
 Time frames for delayed repair

• Biliary Peritonitis  (in leak) duct

dilates to > 1 cm in 2-3 months time

Strasberg’s recommendation – 3 months

• Biliary obstrn: Early intervention

 Early repair only if
• No infection/collection/fistula

• No multi organ failure

• Good abdominal wall

• Good length and quality of duct

• Minimal inflammation

• Experienced team
 Type A
Post-operative Management

• Drainage of collection + ERCP and stenting

 Type B
Post-operative Management

• Symptomatic patients:
Hepaticojejunostomy,
Segmental hepatic resection, if anastomosis not possible
(only for recurrent cholangitis not manageable conservatively)

• Asymptomatic:
Diagnosed after long duration : No treatment is required
Recently diagnosed, drains a large portion of liver : Bypass

procedures
 Type C
Post-operative Management

• Drainage of collection ± biliary enteric

anastomosis

• Resection of the liver, if the drainage segment

is small
 Type D
Post-operative Management

• ERCP + Stent as initial treatment (usually

resolves)
 Type E
Post-operative Management

• Complete transection – Roux en Y hepatico

jejunostomy

• CBD occlusion (clips, stricture) – ERCP 

Balloon dilation and Stents  if not responding,
Roux en Y hepatico jejunostomy
 Complete Ligation

• Pt presenting with progressive jaundice

reaching a plateau  may suddenly drop
due to development of fistula

• Cholangitis

• Leak
 Complete Ligation - Management
MRCP

Clips / ligature Clips / ligature

without division with division

ERCP  try to
dislodging clip
- Control sepsis
- Multiple PTBD catheter
- Discourage prolonged
Stenting If failure abdominal drain  intestinal
fistula
- Delayed repair 
hepaticojejunostomy
Late post-operative recognition with jaundice with
no sepsis (Biliary stricture)

• Usually a sequelae of ischeamia– dissection at cystic duct CBD jn.

• Definitive major surgery is needed (Hepatico-Jejunostomy)

• Thorough evaluation of disease (MRCP)

• Level of injury
• Coagulation profile
• Liver function
• Evidence of cirrhosis / portal hypertension
• Presence of internal fistula

• Evaluation of physical condition

• Laparoscopic procedure has less morbidity

 Total injury break-up

Type A Type B Type C Type D Type E1 Type E2 Type E3

(27) (nil) (5) (14) (2) (3) (1)

• Primary lap management – 24

- Choledochojejunostomy – 2, T-tube – 5, Suture – 17
• Conversion – 8
- Hepaticojejunostomy – 5, Choledochojejunostomy – 1, T-tube – 2
• Primary ERCP & stenting – 10
• Re-laparoscopy followed by ERCP – 4
• Conservative (needle aspiration) – 6
Prevention
Prevention is
is better
better than
than cure
cure
Prevent
Prevent CBD
CBD Injury
Injury
 Per Operative Injuries
Are We Negligent?

?
YES NO ???
(If we don’t)
Injuries are
•Recognize and act •often known complication
•Do honest introspection
• Often difficult situations
• Assess own ability
(Inexperience) • Often abnormal anatomy

•Don’t Seek •Don’t Transfer the Repair even if But

help patient to sp. centre inexperienced Can We Save
Ourselves?
 Impact of BDI

Happy Lawyer Angry Relatives

Horrified Surgeon

Burdened Administration Poor Patient