1. Bile Duct Injury

2. COMPLICATIONS ARE PART OF LIFE
Incidence: 0.2%
Incidence: 100%
BETTER AVOIDED THAN MANAGED

3. Better avoided than managed
Bile duct injury – a major complication of cholecystectomy
Better avoided than managed

4. Incidence of Bile Duct Injury
Open cholecystectomy: – 0.4%
Lap cholecystectomy: – 0.6%
85% injury occur during lap. attempt
15% injury occur after conversion
Incidence of BDI highest in ‘Mini Cholecystectomy’
Mortality after open cholecystectomy: %

5. Bile Duct Injuries 15% of injuries are recognized on table
Majority - present in early post-op period
Good number – present late –
Sepsis
Jaundice

6. 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):

7. Special Features of Lap BDI
Often Associated with Vs. injury
50% of Type E injuries are associated with Vs. injuries
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
Stump matures
Level of ischemia is evident
Injured Rt. Hepatic Art
Anastomotic Hilar plexus between Rt and Lt Hepatic art.
Axial branches

8. BDI in Open Cholecystectomy
10% present in 1st week
70% present after 6 months
Commonest – Type B & Type D  partial ligature of CBD

9. Laparoscopic Biliary Injuries Strasberg’s ClassificationD
Biliary leak from duct, not communicating with main ductal system
Biliary leak from a minor duct still in continuity with main duct
Occlusion of a part of biliary tree
Lateral injury
E1 to E5 – Bismuth Classification E1
CHD
> 2 CMS. E2
CHD
< 2 CMS. E3 E4 E5
Lap BDI are higher injuries mostly Bismuth 2!

10. A BDI becomes a Complex BDI when…..
Type E2 and higher injury
Previous failed repair
Associated Vs. injury
Cirrhosis
Portal HTN
25-35% of BDIs – complex injuries
Mortality rate in complex BDI – 7.2%
L/C  87.5% of complete
transection are complex
O/C  72% are complex

11. 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

12. Very late presentation
Recognition of BDI
Per Operative
Post Operative
Very late presentation
Detection on table around %
Stricture

13. Injuries Recognised on Table

14. Type A Injury Type A Commonest Injury- (51.9%) Cause
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
Friable tissue
Large duct
Sequential clipping
Mis-identification of Duct of Luschka
Liver bed dissection in deeper plane
Management options
Proper clipping with appropriate size
Ligature
Endoloop

15. Type A Injury Cause Type A Type A Inadequate closure of cystic duct
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
Friable tissue
Large duct
Sequential clipping
Mis-identification of Duct of Luschka
Management options
Suture close
Drain
If persists – ERCP with stenting

16. Type B Injury Type C Injury Causes
Occlusion of a part of biliary tree
Never detected on table
Biliary leak from duct, not communicating with main ductal system
Causes
Misidentification of anatomy
Injudicious use of diathermy / clip for bleeding
Too deep dissection in liver bed
Aberrant RHD

17. Type B & C Injury - Causes
Abnormal Anatomy
Cystic duct draining into Aberrant RHD

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

19. Type B & C Injury - Causes
Abnormal Anatomy
Aberrant RHD with low insertion

20. 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
Redit Sectorial Duct Injury, show the repair & POC

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

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

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

24. Type E - Complete Transections - the most dreaded
Cause
Wrong direction of traction

25. Type E - Complete Transections - the most dreaded
Cause
Abnormal anatomy
RHD draining into cystic duct
Short cystic duct

26. Type E - Complete Transections - the most dreaded
Cause
Dissection of cystic duct-CBD junction rather than cystic duct-infundibular junction

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

28. Type E - Complete Transections - the most dreaded
Cause
Mirrizi and Scarring

29. 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

30. Typical sequence of Type E injuries
A - Normal Anatomy
B - CHD Misidentified as Cystic duct
C - Complete transection of CBD with loss of segment + Injury Rt. Hepatic Artery
D - Hepatic artery clipped ~ Vs injury
Occurs in 50% of cases A B C D

31. Possible sites and mechanism Type E injuries

32. THE FINAL COMMON PATHWAY OF MOST INJURIES IS EITHER TECHNICAL ERROR OR MISINTERPRETATION OF ANATOMY
L H Blumgart

33. Management Type E Injury

34. 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

35. 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

36. 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

37. Injury Recognized on table
POC
No flow in prox duct
Obstruction
Clip?
Leak
Accessory duct / Segmental duct
If < 3 mm  Ligate
If > 3-4 mm (Likely to drain multiple segments repair.
CHD/CBD injury
Immediate repair or
Controlled fistula
Once leak seen  no tissue to be divided unless POC is done

38. 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

39. Thank you

40. BDI presenting in early Post – Op period

41. 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

42. Injury could be Complete obstruction Leak
Progressive obstructive jaundice
Deranged LFT – evident from Day 2 / 3
Leak
Fistula – evident if drain present
Bilioma
Biliary peritonitis
Sepsis
Without sepsis

43. 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

44. 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

45. Actions to be Taken – Step II
USG / CT guided
aspiration with pigtail
Small collection responding
large collections or Biliary peritonitis
Multiple loculi
Re-laparoscopy / laparotomy  peritoneal toileting & drainage

46. Actions to be Taken – Step III (After control of sepsis)
MRCP / Fistulogram – if drain is present
Correct diagnosis
Type & extent of injury

47. Strasberg’s algorithm for repair
Classify Injury
Sepsis control
Drainage of all segments
Reassessment of injury
Patient preparation
Definitive repair

48. 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

49. 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

50. Post-operative Management
Type A
Post-operative Management
Drainage of collection + ERCP and stenting

51. Post-operative Management
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

52. Post-operative Management
Type C
Post-operative Management
Drainage of collection ± biliary enteric anastomosis
Resection of the liver, if the drainage segment is small

53. Post-operative Management
Type D
Post-operative Management
ERCP + Stent as initial treatment (usually resolves)

54. Post-operative Management
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

55. Complete Ligation
Pt presenting with progressive jaundice reaching a plateau  may suddenly drop due to development of fistula
Cholangitis
Leak

56. Complete Ligation - Management
MRCP
Clips / ligature without division
Clips / ligature with division
ERCP  try to dislodging clip
- Control sepsis Multiple PTBD catheter Discourage prolonged abdominal drain  intestinal fistula Delayed repair  hepaticojejunostomy
Stenting
If failure

57. 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

58. Total injury break-up Type A (27) Type B (nil) Type C (5) Type D (14)
Type E1 (2)
Type E2 (3)
Type E3 (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

59. Prevention is better than cure
Prevent CBD Injury

60. Per Operative Injuries Are We Negligent?
YES
(If we don’t)
Recognize and act
Do honest introspection
Assess own ability (Inexperience)
NO ???
Injuries are
often known complication
Often difficult situations
Often abnormal anatomy
Don’t Seek help
But
Can We Save Ourselves?
Don’t Transfer the patient to sp. centre
Repair even if inexperienced

61. Burdened Administration
Impact of BDI
Happy Lawyer
Angry Relatives
Horrified Surgeon
Burdened Administration
Poor Patient

62. Thank you