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IATROGENIC BILE DUCT INJURIES
DR RAJNEESH VARSHNEYMS, DNB
SURGICAL GASTROENTEROLOGIST
SRMSIMS, BAREILLY
Widespread acceptance in early 1990’s “Gold Standard” treatment for gallbladder
removal
General advantages of LC—MIS approachReduced hospitalization Improved recovery timeDecreased PO pain Improved cosmesisReduced cost
LC has been associated with a higher incidence of IA bile duct injuries
LC—0.4 to 0.8% Traditional OC—0.1-0.3%
Association: Increased mortality and morbidity Reduced long-term survival Reduced quality of life
Infrequent—but among the leading sources of malpractice claims against surgeons.
Between 34% and 49% of surgeons are expected to cause such an injury during their career.
Awareness and preventative methods are of clinical importance to surgeons.
Risk FactorsAnatomical
◦ Anatomical variations (biliary and vasculature)◦ Bleeding, scarring, obesity
Laparoscopic◦ Lack of Depth Perception, Tactile Feedback, Full
Manual Maneuverability Improper surgical approach
◦ Improper Lateral retraction (insufficient or excessive)◦ 0 degree scope◦ Approach plane too deep
Lack of conversion to OC during difficult cases
Anatomical Misidentification: excision, incision, or transection of biliary anatomy ◦ Injuries: common bile duct, common hepatic
duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments
◦Anatomical variations (biliary and vasculature)
Electrocautery, thermal injury: stricture of CBD or hepatic ducts, bile leak
Mechanical trauma: stricture of the biliary ducts, bile leaks
--Mistaking the common bile duct for the cystic duct
PATTERNS OF BILIARY TRACT INJURIES
Inappropriate use of electrocautery near biliary ducts
May lead to stricture and/or bile leaks
Mechanical trauma can have similar effects
Lahey Clinic, Burlington, MA.1994
Type A Cystic duct leaks or leaks from small ducts in the liver bed
Type B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts
Type C Transection without ligation of the aberrant right hepatic ducts
Type D Lateral injuries to major bile ducts
Type E Subdivided as per Bismuth classification into E1 to E5
E: injury to main duct (Bismuth) E1: Transection >2cm from
confluence E2: Transection <2cm from
confluence E3: Transection in hilum E4: Seperation of major ducts
in hilum E5: Type C plus injury in hilum
Type 1 Leaks from cystic duct stump or small ducts in liver bed
Type 2 Partial CBD/CHD wall injuries without (2A) or with (2B)
tissue lossType 3 CBD/CHD transection without (3A) or with (3B)
tissue lossType 4 Right/Left hepatic duct or sectoral duct injuries
without (4A) or with (4B) tissue lossType 5 Bile duct injuries associated with vascular injuries
1– Insecure closure of cystic duct; too deep dissection into gallbladder bed
2 – Incision of CBD instead of cystic duct for operative Cholangiogram; Clipping of CBD but recognized; Laceration of cystic duct/CBD junction; Diathermy injury to CBD/CHD
3 – CBD mistaken as cystic duct, with CBD/CHD transected or Resected; Diathermy injury
4 – Right HD or sectoral duct mistaken for cystic duct
5 – Right hepatic artery mistaken for cystic artery; Diathermy or clip injuries to right hepatic artery
Only 25-33% of injures are recognized intraoperatively If experienced, convert to Open Procedure and perform
Cholangiography (determine extent of injury) If not experienced, perform the cholangiogram laparoscopically
with intent of referring patient (placement of drains) Consult an experienced hepatobiliary surgeon
Quicker the repair, the better the outcome!!!Acute Management
Biliary catheter for decompression of biliary tract and control of bile leaks
Percutaneous drainage of intraperitoneal bile collection
DRAIN
REFRAIN
TRAIN
Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of the bile duct injury.
Broad-spectrum antibioticsNo need for an urgent laparotomy. Biliary
reconstruction in the presence of peritonitis results a statistically worse outcome in patients.
No need for urgent with reconstruction of the biliary tree. The inflammation, scar formation and development of fibrosis take several weeks to subside.
Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.
Patient presents with… Vague abdominal pain, nausea, fever, jaundice, vomiting
InvestigationUltrasonagraphy and CT (ductal dilatation and
intra-abdominal collection)Cholangiogram
• ERCP—biliary anatomy and assess the injury• PTC—define biliary anatomy proximal to injury• MRCP—noninvasive (can miss minor leaks)
MR angiography—vascular injuries
MANAGEMENT OF BILE DUCT INJURY
Preoperative imaging Is there subhepatic abscess or collection? Is there ongoing bile leakage ? What is the level of biliary injury ? Are there associated vascular injuries / Is there evidence of lobar atrophy ?
Corrective Treatment Endoscopic stenting for strictures
T-tube placement for minor lacerations
Primary duct-to-duct repair only if tension free anastomosis available
Biliary anastomosis with jejunal loop for major excisional injuries
Attention to operative details (insufficient close or deep plane)
Stasberg’s critical view of safetyAppropriate Handling of GallbladderCareful use of diathermyRecognition of Biliary and Vasculature
Anomalies
LW Way, et al