1. UNIVERSITÀ DI PADOVA
DIPARTIMENTO DI SCIENZE ONCOLOGICHE E CHIRURGICHE
CLINICA CHIRURGICA II^
Direttore: Prof. Donato Nitti
La calcolosi della VPB oggi TRATTAMENTO DELLE COMPLICANZE DELLA CHIRURGIA MININVASIVA
Donato Nitti

2. LAPAROSCOPIC CHOLECYSTECTOMY IATROGENIC INJURIES
Bleeding from the liver bed: 8%
Bile duct injuries: %
Minor vascular injuries (branches of the epigastric vessels, mesenteric and omental vessels): %
Major vascular injuries (aorta, iliac vessels, vena cava, inferior mesenteric arteries and lumbar arteries): %
Bowel lesions: %
Abdominal wall hematoma: case reports
Catarci, Surg Endosc 2001
Shamiyeh, Langenbecks Arch Surg 2004

3. IATROGENIC BILIARY INJURIES

4. IATROGENIC BILIARY INJURIES
A bile duct injury or stricture is the most serious complication of laparoscopic cholecystectomy (LC)
This incidence appears to be 2-4 times higher than that of open cholecystectomy (OC) ( %)
Biliary injuries that occur during LC tend to be more severe than those encountered with OC
LC is generally performed in a retrograde fashion, the level of injury can be proximal and enter into the second- and third-order bile ducts within the liver parenchyma
McPartland, Surg Clin N Am 2008

5. IATROGENIC BILIARY INJURIES
AUTHOR
BDI incidence following OC
BDI incidence following LC
McMahon, 1995
0.2
0.81
Strasberg, 1995
0.7
0.5
Shea, 1996
Targaroma, 1998
0.6
0.95
Lillemoe, 2000
0.3
Gazzaniga, 2001
Savar, 2004
0.18
0.21
Moore, 2004
0.4
Misra,2004
Gentileschi, 2004
Kaman, 2006
Jablonska, World J Gastroenterol 2009

6. IATROGENIC BILIARY INJURIES MECHANISM
Factors associated with an increased risk of BDI
Anatomical anomalies of the bile ducts and hepatic arteries
Chronic inflammation around the gallbladder
Obesity
Poor exposure
Bleeding in the surgical area
McPartland, Surg Clin N Am Jablonska, World J Gastroenterol 2009

7. IATROGENIC BILIARY INJURIES MECHANISM
70-80% of all IBDI are a consequent of misidentification of biliary anatomy before clipping, dividing and ligating structures
The most common type of BDI during LC is the so-called “classical” laparoscopic BDI that occurs when a portion of the common bile duct is resected with the gallbladder
inflammation in the area of the triangle of Calot can result in close approximation of the cystic duct and common bile ducts
excessive cepahalad retraction on the gallbladder fundus or insufficient lateral retraction on the gallbladder infundibulum
Nuzzo, Am J Surg 2008

8. IATROGENIC BILIARY INJURIES CLASSIFICATION
BISMUTH CLASSIFICATION
IS BASED ON THE MOST DISTAL LEVEL AT WHICH HEALTHY BILIARY MUCOSA IS AVAILABLE FOR ANASTOMOSIS DURING REPAIR OF BILIARY INJURY
TYPE
CRITERIA 1
Low common hepatic duct stricture with a length of common hepatic duct stump of > 2 cm 2
Proximal common hepatic duct stricture with hepatic duct stump < 2 cm 3
Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved 4
Hilar stricture with involvement of confluence and loss of communication between right and left hepatic duct 5
Involvement of an aberrant right sectorial duct alone or with concomitant stricture of the common hepatic duct

9. IATROGENIC BILIARY INJURIES CLASSIFICATION
STRASBERG CLASSIFICATION
STRATIFIES INJURIES FROM TYPE “A” TO “E”, WITH TYPE “E” INJURIES BEING FURTHER SUBDIVIDED INTO E1 THROUGH E5 ACCORDING TO THE BISMUTH CLASSIFICATION SYSTEM
TYPE
CRITERIA A
Cystic duct leak or leak from small ducts in the liver bed B
Occlusion of an aberrant right hepatic duct C
Transection without ligation of an aberrant right hepatic duct D
Lateral injury to a major bile duct E1
Transection > 2 cm from the hilum E2
Transection < 2 cm from the hilum E3
Transection in the hilum E4
Separation of major ducts in the hilum E5
Type C injury plus injury in the hilum

10. IATROGENIC BILIARY INJURIES CLASSIFICATION
STEWART-WAY CLASSIFICATION
IS BASED PRIMARILY ON THE ANATOMIC PATTERN AND MECHANISM OF A PARTICULAR INJURY, INCLUDING THE PRESENCE OF ASSOCIATED VASCULAR INJURY

11. IATROGENIC BILIARY INJURIES INTRAOPERATIVE IDENTIFICATION OF BDI
Sudden unexpected leakage of bile from the liver or soft tissue adjacent to the porta hepatis
Persistent bile leakage after transection of an apparent cystic duct
< 15-20% OF BDI ARE DETECTED DURING LC
Gouma, Dig Surg 2002
Lillemoe,

12. IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI
SYMPTOMS:
LABORATORY:
Indicators of cholestasis and liver funcion:
bilirubin, ALP, AST, ALT, gGT
Sicklick, Ann Surg 2005
Jablonska, World J Gastroenterol 2009

13. IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI
IMAGING:
US-doppler
Abdominal CT:
free-fluid  BILE LEAK
hepatic artery and portal vein injuries
ERCP: confirm BDI
Percutaneous transhepatic cholangiography (PTC):
confirm BDI
define biliary antomy
ColangioMRI:
sensitivity %
gold standard before surgical repair

14. IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI
IMAGING:
US-doppler
Abdominal CT:
free-fluid  BILE LEAK
hepatic artery and portal vein injuries
ERCP: confirm BDI
Percutaneous transhepatic cholangiography (PTC):
confirm BDI
define biliary antomy
ColangioMRI:
sensitivity %
gold standard before surgical repair

15. IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI
IMAGING:
US-doppler
Abdominal CT:
free-fluid  BILE LEAK
hepatic artery and portal vein injuries
ERCP: confirm BDI
Percutaneous transhepatic cholangiography (PTC):
confirm BDI
define biliary antomy
ColangioMRI:
sensitivity %
gold standard before surgical repair

16. IATROGENIC BILIARY INJURIES POSTOPERATIVE IDENTIFICATION OF BDI
IMAGING:
US-doppler
Abdominal CT:
free-fluid  BILE LEAK
hepatic artery and portal vein injuries
ERCP: confirm BDI
Percutaneous transhepatic cholangiography (PTC):
confirm BDI
define biliary antomy
ColangioMRI:
sensitivity %
gold standard before surgical repair

17. IATROGENIC BILIARY INJURIES
Any suspect of BDI ?
study the biliary anatomy:
COLANGIOGRAPHY (PTC / ERCP)
YES
successful repair in 96-98% NO
unsuccessful repair in 98%
Wald, Surg Clin N Am 2008
Lillemoe, Br J Surg 2008

18. IATROGENIC BILIARY INJURIES MANAGEMENT
INITIAL GOAL
CONTROL OF SEPSIS 
CONTROL ONGOING BILE LEAK

19. IATROGENIC BILIARY INJURIES ENDOSCOPIC AND RADIOLOGIC TREATMENT
ERCP:
confirm BDI
temporary internal stent
Percutaneus transhepatic
cholangiography (PTC):
define the biliary anatomy
decompress the biliary
system
Sicklick, Ann Surg 2005
McPartland, Surg Clin N Am 2008

20. IATROGENIC BILIARY INJURIES MANAGEMENT
LONG-TERM GOAL
RE-ESTABILISHMENT OF BILE FLOW INTO THE GI TRACT
PREVENT STRICTURE
PREVENT LIVER INJURY
PREVENT CHOLANGITIS
PREVENT STONE FORMATION

21. IATROGENIC BILIARY INJURIES MANAGEMENT
SURGICAL TREATMENT
IMMEDIATE
DELAYED

22. IATROGENIC BILIARY INJURIES IMMEDIATE SURGICAL REPAIR
LESS THAN 1/3 OF BDI
ARE DETECTED DURING LC
try to define the extent of the injury
if the level of injury is clearly defined and the surgeon is comfortable with biliary reconstruction, immediate repair can be performed

23. IATROGENIC BILIARY INJURIES IMMEDIATE SURGICAL REPAIR
Simple leak from the cystic duct stump found during LC  placement of an additional clip or a suture ligature loop  videolaparoscopy / laparotomy
Complex biliary injuries CONVERT TO LAPAROTOMY
STRASBERG CLASSIFICATION

24. IATROGENIC BILIARY INJURIES MANAGEMENT
SURGICAL TREATMENT
IMMEDIATE
DELAYED

25. IATROGENIC BILIARY INJURIES DALAYED SURGICAL REPAIR
Who?
75% of primary surgeon attempt to repair the injury
themselves  17% are successful
If first repair performed in a hepatobiliary third level center 94% are successful
When?
Some surgeons suggest waiting 4-6 weeks to stabilize
patient
Other surgeons suggest to repair the injury as soon as possible to avoid formation of adeshions
Schmidt, Br J Surg 2005
Flum, JAMA 2003
McPartland, Surg Clin N Am 2008

26. IATROGENIC BILIARY INJURIES DALAYED SURGICAL REPAIR
How?
Lateral ductal injuries (Strasberg type D) without a complete transaction  repaired primarly over an adjacently place T-tube as long as there is no evidence of significant ischemia or cautery damage
More extensive Strasberg type D and E  biliary enteric anastomosis for reconstruction
Schmidt, Br J Surg 2005
McPartland, Surg Clin N Am 2008

27. IATROGENIC BILIARY INJURIES SURGICAL REPAIR
END-TO-END ANASTOMOSIS:
feasible if injured segment is 1-2 cm and the 2 ends can be opposed without tension
Kocher maneuver allows tension-free anastomosis
Connor, Br J Surg 2006
Jablonska, World J Gastroenterol 2009

28. IATROGENIC BILIARY INJURIES SURGICAL REPAIR
ROUX HEPATICOJEJUNOSTOMY:
(most performed anastomosis)
- preferable choice in lesions between the hepatic duct and the lobar ducts (less tension of the anastomosis)
lower number of strictures
Sicklick, Ann Surg 2005
McPartland, Surg Clin N Am 2008

29. IATROGENIC BILIARY INJURIES SURGICAL REPAIR
HEPATICO-DUODENOSTOMY:
PRO:
normal physiology → less ulcers and malabsorbtion
only one anastomosis: easier and faster to perform
post-operatory control through endoscope
no secondary biliary cirrhosis reported
CONTRA:
difficult to perform for proximal bile duct lesions
(75% of lesions)
need to an experienced surgeon
risk of cholangitis
Moraca, Arch Surg 2002
Sicklick, Ann Surg 2005

30. IATROGENIC BILIARY INJURIES CLINICA CHIRURGICA 2 EXPERIENCE
: 850 laparoscopic cholecystectomy
1 aortic lesion (0.11%)
1 jejunal perforation (0.11%)
1 hepatic hematoma (0.11%)
3 bile duct injuries (BDI) (0.35%)
: 6 bile duct injuries refferred from other hospital

31. IATROGENIC BILIARY INJURIES CLINICA CHIRURGICA 2 EXPERIENCE
Age
Sex
Timing
(days)
Symptoms
Type of BDI
Imaging
Surgery 48 F 15
Bile leak I
CT, ERCP HJ 44 M 62
Cholangitis II
E-E + T-tube 60 28
Jaundice IV 59 32 49 9
Sepsis, bile leak
III
CT, PTC ERCP 51 24 46 IO 52 7 CT 53 3
STEWART-WAY
CLASSIFICATION

32. IATROGENIC BILIARY INJURIES CLINICA CHIRURGICA 2 EXPERIENCE
OUTCOME
COMPLICATION n°
Management
SHORT TERM (<1mo)
Bile collection 2
Percutaneous drainage
Wound infection 1
Antibiotics
LONG TERM (1yrs)
Stricture
ERCP + stent

33. IATROGENIC BILIARY INJURIES STEWART-WAY II

34. IATROGENIC BILIARY INJURIES STEWART-WAY II

35. IATROGENIC BILIARY INJURIES
P.O. CHOLANGIOGRAPHY (+10 D) AFTER HEPATICOJEJUNOSTOMY

36. IATROGENIC BILIARY INJURIES STEWART-WAY III

37. IATROGENIC BILIARY INJURIES STRATEGIES TO PREVENT BDI DURING LC
CAREFUL DISSECTION AND IDENTIFICATION OF STRUCTURES BEFORE TRANSECTION IS THE BEST MEANS OF A FAVORABLE OUTCOME
Meticulus dissection of the triangle of Calot to estabilish the “critical view of safety” before the division of any structures: when the cystic duct and cystic artery are clearly seen, safe clipping and division can be performed
Dissection of the cystic duct–common duct junction
The role of intraoperative colangiography during cholecystecomy is controversial, but is an effective means to delineate the biliary anatomy.

38. IATROGENIC BILIARY INJURIES
"...whenever the anatomy of the triangle of Calot cannot be clearly defined, conversion to an open procedure is indicated and should not be viewed as a failure or a complication."
McPartland, Surg Clin N Am 2008