Biliary Injury During Laparoscopic Cholecystectomy Dr. Lam Tang Yu Department of Surgery, Tuen Mun Hospital Joint Hospital Surgical Grand Round (JHSGR) Ruttonjee Hospital, 24/10/2015

Outline Incidence Cases sharing Risks factors Presentation, classification and management Prevention

Incidence of Biliary Injury In Cholecystectomy Incidence for open, 0.1-0.2% (1-2) Incidence for laparoscopic cholecystectomy, 0.3 – 0.7% (1-2) SOMIP 2013-2014 (11) : - 1884 elective cholecystectomy - 97.6% laparoscopic approach; 6.3% conversion (115) - 0.6% biliary fistula - 0.1%, 1 case CBD injury (0.2%, 3 cases in 12/13, 11/12)

Our center in the past 5 year Case I: Laparoscopic cholecystectomy for chronic cholecystitis, 2012 - CBD confluence injury - Hepatico-jejunostomy performed 3 months later - recover uneventfully CBD confluence injury in 04/2012 We performed HJ in 08/15 Recovery uneventfuly

Our center in the past 5 year Case II: Symptomatic GS with lap cholecystectomy, 2015 - jaundice on post-op day 2 - CT: dilated biliary tree - percutaneous transheaptic cholangiogram + external drainage - HJ performed three months later

Risks factors Main risk factor were thought: inexperience aberrant anatomy inflammation Review by S M Strasberg (10) in 1995: - initial report: learning curve did related to injuries - later reports: the more experienced the more common for biliary injury

Risks factors An analysis (3) in 2003 (252 biliary injury cases) visual perception illusion in 97% of cases experience NOT related

Management of Biliary Injury depends on time of recognition Intra-operative recognition less than 1/3 patient (4) consult an experience surgeon convert to laparotomy with cholangiogram, define the nature of injury repair accordingly: primary repair / T-tube / HJ higher successful rate, few morbidity/mortality (5)

Intra-operative recognition If expertise not a/v: no attempt should be made; as would cause further biliary / vascular injury external biliary drainage, drain to sub-hepatic space refer to specialized hepatobiliary center Stewart et al. (1995): 1. Repair success rate: 17% (primary surgeon) Vs 94% (tertiary biliary surgeon) 2. Hospital stay: 222 Vs 78 days 3. Morbidity: 58 Vs 4% 4. Mortality: 1.6 Vs 0% Flum et al. (2003): adjusted hazard of death during follow-up was 11% greater if the repairing surgeon was the same as the injuring surgeon Heise et al. (2003): no. of repairs before referral was a significant predictor of poor outcome

Post-operative recognition Presentation: - abdominal pain, fever, bile from drain, bile peritonitis - bilirubin may elevated - secondary biliary cirrhosis - or any deviation from an uneventful postoperative course

Principle of management for post-op recognition: 1. Control of sepsis and fluid resuscitation 2. Delineate biliary anatomy / vascular injury USG, MRCP CT PTC for biliary drainage + cholangiogram ERCP +/- stenting for leakage injury 3. Definitive treatment: re-establish biliary enteric continuity

A lot of Classification…

Classification: Bismuth classification for benign biliary stricture, 1982 In general, the higher the injury / stricture, the more difficult is the repair and the greater the recurrence Bismuth, developed in the era of open surgery, 1982

Classification: Strassberg - Bismuth, 1995 Strassberg: including other types of laparoscopic injury

Classification: Strassberg-Bismuth, 1995

Classification: Stewart-Way, 2003 Class I: injury occurs when CBD mistaken for cystic duct, but the error is recognized before CBD is divided; or make a small cut for cholangiogram Class II: damage to CHD from clips or cautery used too closed to the duct, often occurs in case of visibility is limited due to inflammation / bleeding Class III: CBD mistaken as cystic duct, then transected CHD unknowingly as the gallbladder separated from liver; subdivided into four sub-classes (similar to Strassberg Es) Class IV: damage to right hepatic duct as mistaken as cystic duct, often combination injury to right hepatic artery as mistaken as cystic artery Stewart proposed a classification system based on the mechanism of the injury

Definitive treatment (10) Strassberg Classification Surgical procedure A ERCP + stent +/- sphincterotomy B - Conservative for asymptomatic; - HJ for symptomatic; - Liver resection when biliary-enteric anastomosis not possible C - HJ; - Ligation if HJ not possible D ERCP; T Tube; HJ E HJ

Definitive treatment for associated vascular injury arterial disruption: -bile duct ischemia -higher rate of anastomotic leakage an independent predictor of mortality, with 38% of patient compared to 3% (6) some suggested routine arteriography before repair consider arterial reconstruction during HJ CT showed any liver atrophy / ongoing sepsis => liver resection

Timing for re-construction is variable… S M Strasberg (10) advocated delay repair: greatest inflammation at the initial post-operative period the process of cauterization and devascularization injury may progress over months

So how late is delay… Ajay K Sahajpal et al (69 cases) (7): - advocated immediate repair (0-72 hours) or late repair (>6 week) intermediate repair significant associated with biliary stricture de Reuver et al (151 cases) (8): repair within 6 week significant higher rate of stricture Lygia Stewart and Lawrence et al (307 cases) (9): - success depend on: complete eradication of abdominal infection; pre-op complete cholangiography; repair by experienced biliary surgeon - no correlation between timing of reconstruction minimal peritoneal contamination / sepsis=> early repair wait for sepsis / soiling resolved => delay repair

Tips of successful HJ preoperative placement of trans-hepatic tubes common hepatic duct should be open as proximal as possible use extra-hepatic portion of the left hepatic duct for a wide anastomosis for E4, joining individual hepatic ducts before jejunal anastomosis

Most importantly: prevention indication for cholecystectomy… perform a safe laparoscopic cholecystectomy correct traction identification of supraduodenal CBD before any dissection start dissection start at the junction of the gallbladder and cystic duct avoid thermal injury, use electrocautery sparingly and with short burst

CRITICAL VIEW of SAFETY - the hepatocystic triangle cleared of fat and fibrous tissue - cystic plate exposed (1/3 of gallbladder separated from liver) - TWO and ONLY TWO tubular structures entering the gallbladder use intra-operative cholangiography if any doubt consider conversion / fundus first / subtotal cholecystectomy

Bring Home Message Perform safe laparoscopic cholecystectomy Convert open / consult expertise if any doubt Resuscitation, control sepsis, delineate anatomy and repair by expertise are important factors for successful management of biliary injury

Reference 1. Deziel DJ, et al, 1193; Complication of laparoscopic cholecystectomy; a national survey of 4292 hospital and an analysis of 770604 cases 2. Vecchio R et al, 1998; Laparoscopic cholecystectomy, an analysis on 114005 cases of United State series 3. Way LW et al, 2003; Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective 4. Stewart L, Way LW, 1995; Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the result of treatment 5. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy; perioperative results in 200 patients, 2005 6. Schmidt SC et al, 2004; Management and outcome of patients with combined bile duct and hepatic arterial injured after laparoscopic cholecystectomy 7. Ajay K. Sahajpal et al, 2010; Bile duct injuries associated with laparoscopic cholecystectomy timing of repair and long-term outcomes 8. De Reuver PR et al, Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury 9. Lygia Steway et al, 2009: Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcome 10. Steven M. Strasberg, 1995: An analysis of the problem of biliary injury during laparoscopic cholecystectomy 11. Surgical Outcomes Monitoring & Improvement Program (SOMIP) report 2013-2014 Reference

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