BILE DUCT INJURIES

Dr. Joe M Das

Junior Resident
S3 Unit

 Bile duct injuries represent a

complex clinical scenario seen with
increased frequency owing to
aberrant anatomy and
more lap cholecystectomies being
performed

Incidence :
0.1-0.2 % in open cholecystectomy
0.4-0.6 % in lap cholecystectomy

HISTORY

 Earliest known gall stones Priestess of Arnan (1085-945 BC)

- Egyptian
Recognition of gallstones was
first recorded by a Greek
physician Alexander Trallianus
(525-605 BC)
The first clinical description of
gallstone disease - Gordon
Taylor, in his description of the
symptoms manifested by

 Observations of human gallstones were

first demonstrated during autopsy by
Gentile da Foligno (1341) in Padua
In 1667, Michael Entmuller said, There
are no medicine which will cure
gallstones.
Jean Lovis Petit (1674-1750)
identifying the biliary colic and other
signs of this disease
removing the gallstones after
puncturing the gall bladder with
trocar and cannula in 1743.

 John Stough
Bobbs - first
elective
cholecystostomy
in Indianapolis
for hydrops of
the gallbladder
In 1878 Kocher
drained an
empyema of
gallbladder.

 Ludwig Georg
Courvoisier
(1843-1918).
Law (Statistical
article on the
pathology and
surgery of the
biliary system)
First
choledocholithoto
my
Butterflies

First open
cholecystec
tomy
Dr Carl
Johann August
Langenbuch
(German
surgeon)
July 15, 1882,
at Lazarus
Krankenhaus
in Berlin

 Bernard
Naunyn (18391925) pathophysiologi
cal basis of gall
stone formation
Hans Kehr inventing a T
tube

First
laparoscopic
cholecystecto
my
Erich Mhe in
Germany in
1985

 The first laparoscopic

cholecystectomy in India was done in
1990 at the J.J. Hospital, Mumbai

"The pleasure of a physician

is little, the gratitude of
patients is rare and even
rarer is material reward, but,
these things never deter the
student who feels the call
within him
BILLROTH

REVIEW ON SURGICAL
ANATOMY

Extra hepatic biliary tract

Left hepatic duct segment 2,3,4.
Right hepatic duct
Right anterior: 5,8
Right posterior:6,7
Hilar plate : seperates biliary
confluence from posterior aspect of
caudate lobe.
Common hepatic duct lies
anterolateral to hepatic artery and
vein in the hepatoduodenal ligament.

 Common bile duct :

Length : 5 to 9cm
Diameter : 6 to 8 mm
Supraduodenal , retroduodenal &
intrapancreatic .

Gall bladder :
7 to 10 cm length.
30 to 60 ml capacity.
Fundus ,body infundibulum and neck

 Cystic duct :
Length : 1 to 5 cm
Diameter : 3 to 7 mm

Blood supply :
Distal :
Gastroduodenal,retroduodenal,
pancreatoduodenal arteries
Proximal : Right hepatic and cystic
arteries.

Arteries run parallel to each

other at

Common bile duct

Calots triangle
(Hepatobiliary / Cystohepatic triangle)
Common hepatic duct ,liver and
cystic duct.
Cystic artery, RHA & lymph node.

Duct of Luschka (Accessory hepatic /

cholecystohepatic duct)

Variations of Accessory duct at Porta

Hepatis

Anatomical variations of Gall

bladder

Agenesis of GB : 0.02%.

Cholangiography

Multiple Gall Bladder

1 in 3800.
Should be
removed even
when normal.
Magnetic or CT
cholangiography

Ectopic Gall Bladder

Normally formed gall bladder in
an abnormal site.
Intrahepatic , left sided ,
transverse or retrodisplaced.
Floating gall bladder : suspended
via a mesenteriole.

Intrahepatic & floating

Cystic duct Anomalies

Only 33% have classical anatomic
position and course.
Most important : junction of cystic
duct with CHD
Length varies : 20% < 2cm ,majority
2-4cm.
Careful dissection of the Calots
triangle.

(a)Low & parallel course (15%)

(b)Adherent to CHD (6%)

(c)Normal course of the cystic duct(60)

(d)Short & absent cystic duct(3.5&0.5)

(e)Anterior spiral course to left of

CHD(2)
(f)Posterior spiral course to left of
CHD(13)

Variations of CBD & Extra hepatic

confluence.
Convergence of hepatic ducts vary
greatly.
Sectoral ducts: nonconfluence of the
ducts with independent ending for
each duct in duodenum.
Length of CBD varies from person to
person.

(a) 1.4% (b) 2.6%

(c) 0.16% (d)0.08%

(e) 10.7% (f) 85%

Cystic dilatations of biliary tree

Todani Classification

 Ty 1- Solitary fusiform extrahepatic cyst.

Ty 2 Extrahepatic supraduodenal
diverticulum.
Ty 3 Choledochocele - intraduodenal
diverticulum
Ty 4a Fusiform intra & extrahepatic cysts.
Ty 4b Multiple extrahepatic cysts.
Ty 5 Carolis disease (multiple
intrahepatic cysts)

Cystic artery variations

20% cases arise from middle & left
hepatic artery.
Replacements : gastroduodenal
,celiac axis or independently from
aorta.
Abberant RHA from SMA .
Double cystic artery.

Diagram shows cystic artery classification based on the relationship of the cystic artery to
the Calot triangle.

Sugita R et al. Radiology 2008;248:124-131

2008 by Radiological Society of North America

Causes of bile duct injury

CYSTIC DUCT INJURIES AND BILE

LEAK
Cystic duct : 50%
Subvesical or Gallbladder bed : 25%
Major bile duct :25%

 Cystic duct leak

failure to safely ligate the cystic
duct
failed application of endoscopic
clips.

Acute cholecystitis : wide and

friable cystic duct.
Intraoperative cholangiogram
Endo-loop application is better.

Clinical features and

investigation
Excessive right upper quadrant pain
and elevated bilirubin.
Ultrasound or CT
HIDA (hepatobiliary iminodiacetic acid)
ERCP : procedure of choice

Extra hepatic bile duct

injuries
Common hepatic duct most
commonly injured.
During dissection of Calots triangle
& inadequate identification of the
structures.
Either partial lacerations or complete
transections.

Intrahepatic bile duct

injuries
During dissection of gallbladder off
the liver bed.
Right hepatic duct more commonly
injured than left.
Inadequate / incomplete
cholangiogram : convert to open.

Cause of biliary strictures

Direct injury
Clipping of duct
Thermal injury
Ischaemia
Inflammation and scarring
secondary to bile leakage.

Mechanisms of injury and risk

factors
Anatomic variations.
Complicated pathology.
Technical error.
Thermal and laser injuries.

Complicated pathology
Acute inflammation and scarring of
the triangle of calot.
Acute cholecystitis.
Acute pancreatitis.
Chronic cholecystitis.
Mirizzi syndrome
Perforated duodenal ulcer.

Technical errors
Cephalad and lateral retraction of
gall bladder is necessary to expose
the structures.
Cautious retraction in case of acute
inflammation or gangrenous gall
bladder.
Avoid application of clips too close to
the cystic duct CBD junction.

 Avoid strenous dissection too

close to the CBD.
Blind application of clips to
achieve hemostasis.
Willingness to convert to open
technique.
Early in the surgeons learning
curve.

Thermal and laser injuries

Use of electrocautery
Avoided near the CBD
Bipolar cautery is better.
Laser : severe injuries with tissue loss.
Avoid usage near metallic clips
Low intensity for short duration

CLASSIFICATION

Bergmann classification of bile

duct injuries

Stewart Way classification of

Laparoscopic bile duct injuries

A drawback of
the Bismuth
classification is
that patients
with limited
strictures,
isolated right
hepatic duct
strictures, or
cystic duct leaks
cannot be
classified

Strasberg
classification is
able to classify
all types of
injury and is
used extensively
in describing bile
duct injuries
associated with
laparoscopic
cholecystectomy

 McMahon
Amsterdam Academic Medical
Center's classification (1996)
Neuhaus' classification (2000)
Csendes' classification (2001)
CUHK (Chinese University of Hong
Kong), 2007

What are the clinical features

and how to detect these
injuries?

 Most class I injuries are

recognized intraoperatively (about
6070%).
Those unrecognised present with
mild abdominal pain, abdominal
distention, ileus, with mild
elevations in ALP (average 250 U/l)
and bilirubin (average 2.3 mg/dl)
Ultrasound and CT scans
demonstrate an abdominal fluid
collection without dilated bile ducts

 The majority of class II injuries (6070%)

present with
Obstructive jaundice, pruritus,
cholangitis, bilirubin and alkaline
phosphatase levels.

The remainder of the patients, who have

associated biliary fistulas, present similar
to class I injuries.
Some patients may have a prolonged bile
leak from surgically placed drain that then
closes, with the subsequent development
of a biliary stricture and jaundice

 CT and USS
dilated bile ducts in patients without
biliary fistulas
non-dilated ducts and abdominal fluid
collections in patients with associated
biliary fistulas.

ERCP shows the lesion, invariably

with multiple clips overlying it with
or without a fistula.

 Patients with class III injuries present

like class I injuries, only they can
have a more toxic illness.
About 25% of these injuries are
recognized during the index
operation when bile is seen to drain
from the common (or hepatic) duct.
The remainder of patients present
later with abdominal pain, abdominal
distention, ileus, and cholangitis

 Laboratory abnormalities are

highly variable
Total bilirubin can be normal
or elevated (average of 45
mg/dl)
Alkaline phosphatase can be
normal to elevated (average
of 225 U/l)
White blood cell count
similarly can be normal to

 CT and ultrasound scans - an abdominal

fluid collection and nondilated bile
ducts.
ERCP distinguishes class III from other
bile duct injuries involving a biliary
fistula.
The findings in class III injuries consist of
a truncated common bile duct that is
occluded with a clip, and non-filling of
the biliary radicles .
PTC demonstrates the proximal extent of
these injuries.

 Class IV injury patients present with

abdominal pain, abdominal distention,
ileus, cholangitis, hepatic abscess (20
25%)
Unlike the other injuries, many (45%) of
these patients can have associated
severe hemorrhage requiring blood
transfusions.
CT and USS non-dilated ducts and fluid
collections
ERCP - injury to or occlusion of the right
hepatic duct (or a right sectoral duct) by
a clip

Routine intraoperative
cholangiography
Fletcher et al. in 1999 found that
intraoperative cholangiography had a
protective effect for complications of
cholecystectomy in a retrospective
study of 19,000 cholecystectomies.

Is it possible to detect
these injuries intra
operatively?

Intraoperative clues to a bile duct

injury
Cholangiogram abnormalities:
Failure to opacify the proximal hepatic ducts
Narrowing of the CBD at the site of
cholangiogram catheter insertion

Bile drainage:
Drainage of bile from any location other than
a lacerated gallbladder
Bile draining from a tubular structure

 Atypical features of cystic duct:

A cystic duct that is not completely
encompassed by the standard M/L.
clip, which measures 9mm in the
closed position, the structure may be
the common duct
A cystic duct that can be traced
without interruption behind the
duodenum, that will prove to be the
common duct, not the cystic duct

 Anomalous anatomy:
Second cystic duct, aberrant duct,
accessory duct, or suspected duct of
Lushka, these are generally the common
duct or a hepatic duct
Second cystic artery, this may be the right
hepatic artery
Lymphatics surrounding the cystic duct or
more tissue around the cystic duct than is
usually encountered, this indicates that
the dissection is in the porta
Fibrous tissue in the gallbladder bed,
indicates transection of the proximal
hepatic ducts

How to prevent?

 Proper selection of cases

In obese patients place the optical port little
higher up from the umbilicus to avoid the
tangential view of the Calots triangle.
Posterior peritoneal fold should be opened
before approaching the Calots triangle
anteriorly. This provides an extra mobility to
GB and helps the CHD to fall away from the
CD thereby avoiding proximal BDI during the
dissection of Calots triangle.
Always dissect to the right of the line joining
the right free margin of lesser omentum to
cystic node.

 While dissecting the Calots triangle

stay close to the GB.
It is advised that Calots triangle is
dissected in such a way that the
retro-infundibular window is opened
first and then the window between
the cystic artery and duct is opened.
Visualisation of the double window is
called Critical view of Strasberg.

critical view of
safety of
Strasberg
Calots triangle
is completely
unfolded by
mobilizing the
gallbladder neck
from the
gallbladder bed
of the liver
before
transecting the
cystic artery and

 Always dissect to the right of the line joining

the right free margin of lesser omentum to
cystic node.
Vessels pulsating before clipping should be
considered as hepatic artery until proved
otherwise.
While dissecting GB from the liver bed stay
close to the GB and avoid any injury to
superficial portal radical or abnormally
superficial right anterior sectoral duct.
Intra-operative cholangiogram may be used
routinely in order to better identify the
anatomy after dissection of Calots triangle.

 Once the Calots triangle is fully

dissected and cystic artery has been
clipped and cut, GB is left attached
medially to only one structure, CD.
If the plane between the liver and GB is
absent, it might be better to leave a
part of posterior GB wall adhered to the
liver bed and cauterise its mucosa than
to cause an inadvertent injury to
hepatic parenchyma resulting in bleeds
and postoperative biliary fistula.

 The cystic duct and

the GB neck and
infundibulum
together looks like
Lord Ganeshas
trunk and head (or
elephants trunk
and head)
respectively and so
also called as Lord
Ganeshas sign.

 Use the suction-irrigation cannula to aid

in dissection. The oozing surface absorbs
light with a resultant darker picture.
In case of impacted stone in the neck, it
may be safer to transect the Hartmans
pouch and remove the stone. The left out
mucosa can be cauterised and stump is
sutured.
In case of a dilated CD where clip cannot
adequately close its lumen, it is advised
to use endoloop or intracorporeal
suturing for safe closure of the stump.

In case of excessive bleeding during the

surgery:

Have a low threshold for conversion.

If there is continuous ooze from the inflammed
surface, liberal irrigation and aspiration should
be used.
If there is sudden arterial spurt, compress the
area temporary with small gauge or atraumatic
grasper. Irrigate / aspirate and clean the
operative field. Effectively control the bleeding
vessel with left hand grasper, identify the vessel
and arrest bleeding with clips or bipolar
electrocautery.

I would like to see the day

when somebody would be
appointed surgeon
somewhere who had no
hands, for the operative part
is the least part of the work
-Letter to Dr Henry Christian Nov 20,
1911

MANAGEMENT

HOW ESSENTIAL IS TO TREAT

BILE DUCT INJURIES?

 Most bile duct injuries or strictures

occur as a result of cholecystectomy
for symptomatic gallstone disease.
The majority of these patients are
young (4050 years), female, have a
long life expectancy, and are in the
most productive years of their life.

 Biliary strictures may result in significant

morbidity and mortality secondary to
complications such as biliary cirrhosis ,
cholangitis,portal hypertension.
Because of this, it is essential that these
patients have prompt recognition of their
problem and a reliable treatment with a
long-term success rate.

WHAT ARE THE FACTORS ONE

SHOULD CONSIDER BEFORE
TREATING BILE DUCT INJURIES?

1.Timing of diagnosis -

Intra-operative
Early post-

op

2.Extent and level of injury

3.Patient presentation
4.Hospital setup

Late post-op

WHAT ARE THE TREATMENT

OPTIONS AVAILABLE ?

 A multidisciplinary approach
The team consisting of experienced
interventional radiologists,
endoscopists, and surgeons,
coordinated by an experienced
hepatobiliary surgeon

1) Surgical Management
2) Interventional Radiologic Techniques
3) Endoscopic Techniques

Most of these injuries and strictures

are best repaired surgically.

SURGERY - GOLD
STANDARD

"Surgery is the first and the

highest division of the healing
art, pure in itself, perpetual in
its applicability, a working
product of heaven and sure of
fame on earth"
- Sushruta (400 B.C.)

PRE-OPERATIVE MANAGEMENT

 Early post-op period

Sepsis /SIRS
Treat with Broad spectrum antibiotics
-Percutaneous biliary drainage
- Percutaneous/operative drainage
of bilomas
No hurry for surgical repair
of
small ducts

- friable tissue
-retraction

 Next step- Pre-op cholangiography

(to define
anatomy)
Control bile leak with
percutaneous stents
Delayed surgical repair

 Late post-op period

Strictures
Cholangitis
Treat with- Broad spectrum
antibiotics
Urgent cholangiography
Biliary decompression
-Transhepatic
biliary drainage
-Endoscopic

 If patient presents only with jaundice

& no cholangitis
ERC / PTC -

to define anatomy

In these cases biliary decompression

has not been demonstrated to
improve outcome
Surgical repair

INTRA OPERATIVE MANAGEMENT

 Intra-operatively, any suspicious biliary injury

1) Intra-op cholangiography
+/Careful dissection
2) Lap to open conversion is often
necessary
Isolated, small, noncautery-based partial
lateral bile duct injury
Placement of a
T tube

 Injury involves <50% of the

circumference of the bile duct wall

Primary closure over a Ttube

 More extensive biliary injury

Significant thermal damage owing to
cautery-based trauma
Injury involving >50% of the
circumference of the bile duct wall

End-to-side choledochojejunostomy with

a Roux-en-Y loop of jejunum should be
performed

MANAGEMENT OF HEPATIC DUCT

INJURIES

 Major bile duct injuries, including

transections of the common common
hepatic duct, can be repaired.
Isolated hepatic ducts smaller than 3 mm or
those draining a single hepatic segment can
be safely ligated.
Ducts larger than 3 mm are more likely to
drain several segments or an entire lobe
and need to be reimplanted.

TECHNICAL ASPECTS OF
SURGICAL REPAIR

SURGICAL REPAIR
The blood supply of the common duct is axial
running at 3:00 and 9:00 on the duct.
These vessels are small and easily damaged
during extensive mobilization of the duct.
In addition, the majority of the blood supply
(60%) comes from below, while only 38%
comes from above, further contributing to
ischemia in the proximal portion of the duct

 The choice and technique of

repair correlates with the success
rate.
End-to-end anastomosisThe common duct (or
common hepatic duct) has been
divided and there is sufficient
length to perform an end-to-end
anastomosis without tension

Unsuccessful :
1.When repaired at the initial open
cholecystectomy
2. Class III injuries, especially
laparoscopic.
The reasons for the high failure rate
of end-to-end biliary anastomoses
relate to ischemia and tension.

Roux-en-Y hepaticojejunostomy
Has the best success
rate for the repair of
a transection injury of
CBD/CHD

Certain technical factors for a

successful hepaticojejunostomy are
Preoperative eradication of intraabdominal infection
Viable ductal tissue (excise damaged
ductal tissue)
Single-layer mucosa-to-mucosa
anastomosis
Fine, monofilament, absorbable suture
Alleviate tension on the anastomoses

Stenting
Stenting is useful, however, when very
small ducts are repaired (class IV
injuries or class III injuries where the
resection has been carried high into the
porta).
For other injuries stenting may not be
required.

WHEN DETECTED POST-OP.?

 The management of
postoperative biliary
strictures following ductal
injury depends on the degree
of injury, the presence of
stricture-induced
complications, and the
operative risk of the patient.

 After recognition of a bile duct injury or

stricture, a multidisciplinary team
consisting of experienced interventional
radiologists, endoscopists, and surgeons,
coordinated by an experienced
hepatobiliary surgeon, should plan the
following specific goals:
1. Control the infection (abscess or
cholangitis)
2. Drain the biloma
3. Complete the cholangiography
4. Provide definitive therapy with
controlled reconstruction or stenting

OVERVIEW

Suspected CBD injury during lap-cholecystectomy

Intra-op cholangiogram
Partial injury(<30%)
Primary repair over T-tube
Extensive injury(>30%)
Roux en Y
choledochojejunostomy
Complete transection
Roux en Y.
Injury to isolated hepatic duct
>3mm
Reimplantation or reconstruction
by
Roux en Y hepaticojejunostomy
<3mm
Ligate

Role of Interventional
Radiology

 Interventional
radiologic
techniques are
useful in patients
with bile duct
injuries, leaks, or
postoperative
strictures.

 These techniques allow

1)Percutaneous drainage of abdominal fluid
collections
2)Preoperative identification of the ductal
anatomy through percutaneous transhepatic
cholangiography
3)Stricture dilation with or without
placement of palliative stents for bile
drainage in the patient whose overall
physiologic status precludes a major
operation.

 Percutaneous transhepatic biliary

dilatation:
Intrahepatic ductal disease
ERCP is not possible
Adjunct to operative repair in order to
assist with identification of the
proximal biliary tree for reconstruction
and for the dilation of anastomotic
strictures

ROLE OF ENDOSCOPIC
DILATATION IN BILIARY
STRICTURES

 Adjunctive option in patents with a

dominant extrahepatic stricture
causing clinical symptoms.
Requires multiple sessions of
dilations
Nonischemic strictures
(anastomotic strictures) respond
best.

 Metalic stents are more durable

than plastic stents
Endoscopic dilation also has a
low mortality rate, but it has a
significant morbidity rate.

 Complications following
endoscopic biliary interventions:
Hemobilia
Bile leak
Pancreatitis
Cholangitis
Re-stricture

POST-REPAIR COMPLICATIONS

1.
2.
3.
4.
5.
6.
7.
8.

Cholangitis
Pancreatitis
Stent occlusion
Stent migration
Ductal perforation
Restricturing
Biliary fistula
Hemobilia

MANAGEMENT OF BILIARY
FISTULA

 To define biliary fistula

a bilirubin rich drainage
lasting for more than 5 days
Most of them resolve spontaneously
with conservative management.
3 RS

3 Rs

Resuscitation
Restitution
Rehabilitation

Resuscitation
The first stage in the management
is the restoration of volume using
crystalloid and colloid products as
appropriate to restore oxygen
carrying capacity and plasma oncotic
pressure.
Blood PCV 30%
Albumin -3

 Control of sepsis
Per cutaneous drainage
Antibiotcs should only be given for
defined infections and for a set
duration of therapy
Nutritional support
Cholangiography

Non-operative management
Usually for low output fistula
Percutaneous drainage
Trans-hepatic stenting

Surgical intervention
For early high output fistula
Persistent sepsis

Reoperation

References

Surg Clin N Am 90 (2010) 787-802

Surg Clin N Am 88 (2008) 1329-1343
Schwartz's Principles of Surgery, 9e
Sabiston Textbook of Surgery, 17e

THANK YOU