cbd injury in lap chole

December 15, 2021 By admin Off

– uncontrolled sepsis of the entire biliary tree, in the presence of severe intrahepatic bile duct strictures or metallic stents [67,68,69];

CHD = Common hepatic duct; RHD = right hepatic duct; CBD = common bile duct.

Therefore, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has launched a new initiative in order to improve safety in LC, headed by the Safe Cholecystectomy Task Force (SCTF). This task force seeks to encourage a culture of safety in LC and to reduce biliary injury. To elucidate the crucial issues, an expert consensus study was conducted to identify factors considered most important to reach this goal [31]. The following top five most important factors linked to safe practice were denominated: (i) establishing CVS; (ii) understanding of relevant anatomy; (iii) appropriate retraction/exposure; (iv) knowing when to call for help; (v) recognizing the need for conversion or an alternate procedure (such as subtotal cholecystectomy). However, most of these suggested aspects, even the most widely used, such as CVS and IOC, require initial (blind) opening of the peritoneal layer covering the bile structures and/or cystic plate. In summary, avoidance (prevention) of IBDI requires secure identification of the cystic duct and the cystic artery prior to dissection.

In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.

a, b Critical view of safety (CVS).

Class I Injuries.

– Class IV injuries (10% of cases) involve damage (transection or injury) of the right hepatic duct (RHD) (or a right sectoral duct), often (60%) combined with injury to the right hepatic artery (RHA). Class IV injuries are caused either by misidentifying the RHD (or a right sectoral duct) as the cystic duct and the RHA as the cystic artery; or from lateral injury to the RHD (or a right sectoral duct) during the dissection deep in the triangle of Calot. Because the RHA lies posterior to the CBD, it can be injured or even transected in laparoscopic IBDI [42]. This occurrence is particularly common in cases of resectional class IV injury whereby the RHA is thought to be a large cystic artery and is consequently divided.

Although it has been 25 years since the introduction of LC, as a matter of fact, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery [18]. Efforts to improve safety in LC have greatly increased the body of knowledge regarding all factors relevant to cholecystectomy. These include timing of the procedure and patient selection [19,20,21,22] as well as training and assessment of surgeons performing LC [23]. Endeavors to increase safety of the procedure resulted in optimized intraoperative processes, such as photographic documentation [24] of the ‘critical view of safety’ (CVS), first described by Strasberg and colleagues almost 20 years ago [25]. Using the CVS technique, the Calot’s triangle is completely unfolded by mobilizing the gallbladder neck from the gallbladder bed of the liver. When this view is achieved, the two structures entering the gallbladder (cystic duct and cystic artery) can be definitively detected. Importantly, it is not necessary to see the CBD since such a procedure may disturb bile duct perfusion (fig. ​ (fig.1). 1 ). In addition to this standard procedure, the use of intraoperative cholangiography (IOC) has been propagated by some institutions [26]. Several additional techniques are described to prevent IBDI during LC. Despite the plethora of publications and debates, there is still no consensus regarding the best setting and method, although most surgeons would agree that the CVS [18] and IOC [27] are among the most popular and effective [27,28]. Both of these tools can be used via either laparotomy or laparoscopy. Other methods described include various dissection techniques (infundibular, anterograde, etc.), landmark techniques, Rouvière’s sulcus [29], Calot’s node [30], or use of ultrasound, just to name a few.

The more recently introduced Stewart-Way classification (table ​ (table3) 3 ) incorporates the mechanism of the IBDI as well as its anatomy and has been developed in the era of routinely used laparoscopic surgery. Moreover, this approach is feasible because it provides a tool for prevention of IBDI [41]. The classification also differentiates between resectional injuries and strictures, a distinction which is useful in guiding preoperative evaluation and biliary reconstruction. According to this classification, four types exist (table ​ (table3, 3 , fig. ​ fig.2 2 ):

Cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery, and the laparoscopic approach is now the gold standard for symptomatic cholecystolithiasis as well as for chronic and acute cholecystitis [1]. Besides the advantages of a distinctly faster recovery and better cosmetic results, the laparoscopic approach bears a higher risk for iatrogenic bile duct injury (IBDI) and injury of the (right) hepatic artery. IBDI is a complication associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation [2]. Despite increasing experience and progress in laparoscopic skills of surgeons, the incidence of IBDI is still elevated compared to open cholecystectomy [2]. The rate of clinically relevant bile leaks after conventional open cholecystectomy ranges between 0.1 and 0.5% [3,4,5,6]. In contrast, biliary leakages have increased in the era of laparoscopic cholecystectomy (LC) by up to 3% [7,8,9,10]. A variety of injuries can occur. Besides minor bile leakage of aberrant ducts, cystic stump or the main bile duct, complete occlusion of the main duct or a branch (often an aberrant right duct) can happen. In addition, bile duct strictures and biliary leakages are severe long-term complications after LC. These injuries are associated with high morbidity, mortality, and prolonged hospitalization [11]. Currently, endoscopic procedures are most frequently used in the management of postoperative IBDI. There are several endoscopic techniques available, e.g. biliary stent placement, biliary sphincterotomy, and nasobiliary drainage [12,13,14]. In this respect, endoscopic therapy can reduce the transpapillary pressure gradient and improve the transpapillary flow, which decreases the extravasation out of the biliary tract. This reduction of bile leakage allows healing of duct lesion injuries without direct surgical repair. Nonetheless, if major IBDI occurs, i.e. complete dissection of the common bile duct (CBD), surgical management is required to resolve this issue [15]. In an effort to reduce further complications and injuries in the hepatoduodenal ligament, surgical procedures should be performed in collaboration with skilled and experienced hepatobiliary surgeons, interventional radiologists, and gastroenterologists at a tertiary referral center [16,17].

– Class I injuries (6% of cases) occur when the CBD is mistaken for the cystic duct, but the flaw is recognized during the initial operation and before the CBD is transected.

– acute liver failure following severe vasculobiliary injury [70,71,72];

– Class II injuries (24% of cases) consist of lateral damage to the hepatic duct by unintended application of clips or cautery. These injuries do usually occur when visibility is limited due to inflammation or bleeding. For one reason or another, the surgeon was working too deep in the triangle of Calot, unknowingly close to the common hepatic duct (CHD).

Cystic duct leaks are well manageable; the treatment of choice is endoscopic retrograde cholangiopancreatography and sphincterotomy [13] or endoscopic stenting and drainage of intra-abdominal bile collections. Nearly all cystic duct leaks will close with this management scheme. It is crucial to drain bile collections; the stent only acts to decrease the pressure in the biliary tree and does neither cover the leak nor prevent bile drainage.

IBDI can be a very serious complication that, if managed inadequately, can result in life-threatening complications such as cholangitis, secondary biliary cirrhosis (SBC), and portal hypertension. Even with successful management, quality of life may be diminished and survival may be impaired [47]. In general, these injuries are less commonly managed successfully by the primary surgeon who performs the initial cholecystectomy. Biliary reconstruction by the primary surgeon results in success rates between 17 and 30% [41,48,49,50]. Data suggest that these injuries should be managed by a hepatobiliary surgeon with extensive expertise in biliary reconstruction as outcomes can be excellent; many expert surgical series report long-term success rates of more than 90% [51,52,53,54,55,56,57,58]. Given that management of these injuries often requires an experienced multidisciplinary team (including interventional radiology, gastroenterology, and surgery), they are best handled in a tertiary referral center. It can be claimed that if immediate repair is possible by an experienced surgeon, even a completely transected bile duct can be primarily reconstructed as an end-to-end ductal anastomosis by employing simple interrupted absorbable monofilament stitches; this is a well-established routine in liver transplant (LT) surgery. Several conditions must be met for proper healing of each biliary anastomosis. The anastomosed edges should be healthy; there should be no inflammation, ischemia, or fibrosis; and the anastomosis should be tension-free and properly vascularized [59]. Refreshing of the proximal and distal stumps as far as the tissues are healthy and without inflammation should be performed. End-to-end ductal anastomosis can be recommended for patients when the maximal loss of length of the bile duct is 4 cm. Approximation of both ends is possible by means of a wide Kocher maneuver. Contradictory meta-analyses regarding the usefulness of a T-tube in LT performing end-to-end ductal anastomosis can be found in the literature [60,61]; therefore, the application remains controversial. There is also a second type of T-tube available for biliary drainage, the so-called internal Y-drainage [59]. External T-drainage involves using a typical T-tube with insertion of its short branches into the bile duct, and conducting of its long branch through the abdominal wall outside. It can be removed percutaneously after healing of the end-to-end ductal anastomosis. Internal Y-drainage involves insertion of short branches of the T-tube into both the right and left hepatic ducts, splinting of the anastomosis, and conducting of its long branch into the duodenum by the papilla of Vater. This drainage can be removed endoscopically after healing of the end-to-end ductal anastomosis. It should be emphasized that the internal Y-drainage is less traumatic than the external T-drainage as it does not involve additional incision of the bile duct wall. Therefore, it was suggested as the drainage of choice in end-to-end ductal anastomosis [62,63,64].

RHD = Right hepatic duct; CBD = common bile duct.

Classification of Bile Duct Injuries.

Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries.

CBD = Common bile duct; CHD = common hepatic duct; LHD = left hepatic duct; RHA = right hepatic artery; RHD = right hepatic duct.

Hepatectomy is rarely required for IBDI; however, in case of failure of reconstructive approaches, it remains a necessary option. The ultimate rescue therapy available would be LT, but the indications are exceptional and reserved for patients in whom liver function is so deteriorated that repair or partial hepatectomy is impossible. These include:

Several studies reported that the timing of biliary reconstruction influences the outcome; these series reported worse outcomes for biliary reconstructions performed within 6 weeks of injury [52,54,65]. Stewart and Way [48] examined this question, using multivariate analysis, and noted that the timing of repair was not an independent predictor of successful biliary repair. Instead, success correlated with eradication of intra-abdominal infection, complete preoperative cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. This timing issue most likely relates to the time required to eradicate intra-abdominal inflammation and to achieve nutritional repletion. In this series, good results were achieved with early biliary reconstruction in those patients with good nutrition, good functional status, and early control of intra-abdominal inflammation [48].

Contrary to widespread opinion, the determination of serum alkaline phosphatase and total bilirubin in particular is not sensitive early in the initial postoperative course [43,44]. The majority of patients with IBDI will present within the first few weeks following the index operation [45,46]. The symptoms will be unspecific and may include fever, pain, and mild hyperbilirubinemia (2.5 mg/dl) from biloma or bile peritonitis [17]. Biliary leakage will be suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. In case of injuries involving occlusion of the CHD or CBD without an intraperitoneal bile leak, the main symptoms will be jaundice with or without abdominal pain. In some cases, patients will present with cholangitis or cirrhosis from remote IBDI at a later time, probably months or even years after biliary surgery [25]. In severe early postoperative cases, patients will present with sepsis from cholangitis or intra-abdominal fluid collections. In the case of a suspected bile leak, ultrasound and/or an abdominal computed tomography (CT) scan will identify peritoneal fluid, biloma, or an abscess. In the case of perihepatic fluid collections, drainage can be applied percutaneously. Usually, broad-spectrum parenteral antibiotics covering the common biliary pathogens are initiated [46]. When a percutaneous drainage is applied and ongoing biliary drainage is observed, an active bile leak is verified.

In the future, ultrasound and intraoperative fluorescence cholangiography may help to reduce IBDI. In this respect, near-infrared fluorescence cholangiography (NIRFC) was developed [32,33,34] and a multicenter randomized controlled trial is currently recruiting to compare NIRFC-assisted laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy (FALCON trial) [35]. When employing this method, intravenous injection of a dye (indocyanine green) and use of specific equipment, i.e. an NIR light-emitting xenon-based light source and a camera that is capable of detecting NIR fluorescence emitted by indocyanine green-dyed bile, is required [36]. Neither the dye (at normal doses) nor the equipment is dangerous (no irradiation) for the patient or surgeon. Compared with IOC, NIRFC has been shown to be quicker to perform and to cost less [37]; however, an increased safety has yet to be proven. Theoretically, it should be possible to perform NIRFC in all cases (vs. a 93% rate for IOC) because of the impossibility to cannulate the cystic duct (which represents a dangerous risk factor!) [38,39].

Stewart-Way classification of laparoscopic bile duct injuries (modified from [41]).

Prevention of Bile Duct Injuries.

This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view.

Class I injuries, which are by definition recognized intraoperatively, can be immediately repaired. We recommend fine monofilament absorbable suture (e.g. PDS 6.0). These injuries are usually recognized with cholangiography; thus, only the small incision used to insert the cholangiocatheter needs to be repaired. Insertion of a T-tube catheter is rather contraindicated, as extension of the laceration to facilitate T-tube insertion results in worsening of the injury and an increased risk of stricture [66]. We recommend suturing the incision using simple interrupted stitches.

If IBDI other than class I are detected intraoperatively, there are two options. If a senior hepatobiliary surgeon is available, he or she should be called for immediate reconstruction. If not, drains can be placed (to evacuate bile) and the patient should be immediately referred to a tertiary center for further treatment. As already mentioned, repair by the primary surgeon is associated with less favorable outcomes, and sometimes the attempted repair can further damage the ducts and make subsequent reconstruction more difficult [48,49,50]. Surgeons should take into consideration the extent of injury as well as their own experience and skills in biliary surgery when determining the best approach for management of these biliary injuries.

– bile duct injuries in patients with pre-existing chronic hepatic disease [69].

– patients with SBC with associated liver failure, with or without portal hypertension [67,68,69];

The older classifications are based on peripheral leakages, central leakages, and biliary strictures. Siewert et al. [40] described type 1 lesions, which are peripheral leakages and include immediate biliary fistulas. In contrast, central leakages consist of tangential lesions without structural loss of the bile duct and correspond with type 3 lesions [40]. Type 2 lesions occur when late strictures are diagnosed without obvious intraoperative trauma [40]. Table ​ Table1 1 and ​ and2 2 present the Corlette-Bismuth classification and the Strasberg classification, respectively.

In the setting where a two-step approach has to be undertaken because either the injury was not identified at index surgery or an experienced surgeon was not readily available, the goal of surgical repair should be the establishment of a tension-free, mucosa-to-mucosa duct enteric anastomosis, which in the majority of the cases will be an end-to-side Roux-en-Y choledochojejunostomy or, more commonly, a Roux-en-Y hepaticojejunostomy. In case of strictures involving the bifurcation or left or right hepatic ducts, bilateral hepaticojejunostomies may be necessary [17].

– Class III injuries, the most common (60% of cases), involve transection and excision of a variable length of the duct, which always includes the cystic duct-common duct junction. Class III injuries result from a misperception error whereby the CBD is mistakenly identified as the cystic duct. The surgeon transects the common duct (deliberately, thinking that it is the cystic duct) early in the dissection and then transects the CHD (unknowingly) later in the process of separating the gallbladder from the liver bed. Consequently, the central portion of the extrahepatic bile duct is removed along with the gallbladder.


Fifty-one percent of surgeons in group A and 48% of surgeons in group B completed a cholangiogram during an operation in which an injury occurred ( P = NS). More group A surgeons obtained static cholangiograms in cases in which an injury occurred (24% vs. 17%, P = .05).

Interventions used to treat bile duct injuries and the frequency of their use are shown in Table 8 . Of the 704 injuries reported, 450 (64%) required biliary reconstruction; however, only 15% of these repairs were completed at a referral hospital, and 85% were completed at the hospital where the injury occurred. Bile duct injuries occurring in rural practices were referred to another hospital for definitive treatment 24.1% of the time; those from urban practices were referred 10.2% of the time ( P ≤ .05).


A total of 3,657 questionnaires were mailed, 2,523 (69%) to surgeons in group A and 1,134 (31%) to surgeons in group B. A total of 1,661 surgeons (45%) returned completed surveys, 1,122 (44%) from group A and 539 (47%) from group B ( Table 1 ). The only demographic difference between groups (except age) was that surgeons in group B were more likely to practice in a university or in a public practice (e.g., the Indian Health Service) than surgeons in group A.

Attendance at postgraduate courses in advanced laparoscopy, completion of a postgraduate fellowship, or a fellowship in minimally invasive surgery.

While exaggerating their experience, surgeons are likely to underestimate the frequency of complications; however, this memory bias is unlikely to affect the recollection of catastrophic complications with great emotional impact, such as biliary tract injury. Some critics might impugn a 45% response rate as insufficient to draw conclusions, but given the sensitive nature of these injuries and the fear, by many, of discovery, we believed this response was better than expected. Because the response rate was equivalent between groups, statistical comparisons are valid. Nonetheless, it is likely that these data underestimate the magnitude of the problem, because surgeons injuring bile ducts would be expected to reply less frequently than those free of such injury.

And finally, I would like to offer a different interpretation of your data. The data shows the highest incidence of injury for the Group A surgeons was in their first 25 cases, likely done between the years 1990 and 1993. I would contend that the knowledge obtained since that time concerning the mechanisms of injury and the appropriate techniques to avoid injury, so nicely defined by your senior authors Drs. Branum and Hunter, plus Bill Meyers, Nat Soper, and Larry Way, has made us all much smarter in how to do this operation safely. I would appreciate your comments concerning this point.

The number of LCs completed at the time of the first bile duct injury is shown in Figure 2 . Although a higher percentage of surgeons in group A reported their first bile duct injuries in the first 50 LCs, surgeons in group B reported a greater percentage of total injuries than group A from cases 50 to 200. Combining two surgical volume categories, 40.3% of those in group A and 22.4% of those in group B reported that the injury occurred within the first 50 cases ( P < .001) ( Fig. 3 ). Further, the percentage of surgeons reporting their first injury within their first 100 cases was also higher in group A (56% vs. 43%, P = .008). However, the difference between the groups was not significantly different comparing the number of surgeons who reported their first injury within the first 200 cases. After completing 200 cases, the proportions of surgeons reporting their first injury was similar between groups.

In this survey, bile duct injuries during LC were more commonly found during surgery if a cholangiogram was completed, regardless of the training of the surgeon; however, fewer than half of the surgeons reporting an injury completed a cholangiogram during the operation. More injuries would likely be discovered in the operating room if the use of cholangiography were increased. The overwhelming majority of reported patients with bile duct injuries were treated locally and not sent to referral centers, even if they required biliary reconstruction. Further investigation into the outcomes of locally treated biliary injuries and investigation into the types of injuries or clinical scenarios that should prompt early referral would be of benefit.

Laparoscopic Training and Learning Curve.

Although recent studies have suggested that residency training in LC is associated with excellent outcomes, 14 longer operating times for LC were often reported when residents performed the operation. 15,16 Recent reports show that residents are now performing LC with equivalent safety and in equal time as their attendings, and often in patients who are less healthy than were previously operated on laparoscopically. 17,18 Although these reports suggest that the residency training experience might improve surgical outcomes for LC once these residents are in practice, this has not been established.

* Respondent could choose more than one category of intervention, so percentages may sum to more than 100%.

Despite mounting evidence that biliary injury is less likely when routine cholangiography is used, 24,30–33 respondents completed a cholangiogram in half of the operations in which a bile duct injury occurred. Surgeons in group B were no more likely to have performed a cholangiogram during an index case than surgeons in group A. Despite this, group B surgeons discovered injuries during surgery more frequently than surgeons in group A. This finding may reflect a better understanding of laparoscopic biliary anatomy, a greater vigilance for bile leaks, better videooptics, or one of several other factors. This survey did not attempt to assess the routine use of cholangiography, but it is likely that the rate is similar to the 50% utilization reported in the biliary injury cases. From these data it appears that residency training has little effect on the application of cholangiography, at least in cases in which a bile duct injury occurs.



To support the hypothesis, the authors surveyed practicing surgeons who had learned this operation in two different environments, using their reported numbers of bile duct injuries while in practice as a measure of expertise. The surgeons who had learned how to perform the operation in the educationally deprived setting (Group A) reported more bile duct injuries than the control group (Group B) did, and the excess was confined to the first 200 cases. The findings suggested that learning the operation during residency avoided the complications associated with inexperience, the so-called learning curve.

The results of the questionnaire show that two thirds of bile duct injuries required biliary reconstruction. Although the operation used for repair was not ascertained, hepaticojejunostomy is usually necessary, because the proximal location of injuries and the intense inflammatory reaction at the site of the injury makes more distal repair prone to stricture formation. 28,29 Because treatment of an injury after it occurs is not usually a function of laparoscopic training or skill, it is not surprising that there were no differences between groups in the management strategy and the frequency of referral for bile duct reconstruction.

One of the hallmarks of surgical residency training is graduated responsibility and personal supervision by attending surgeons during operations. After LC was introduced in the United States, most surgeons quickly learned the operation without the benefit of proctoring, and this may have led to the intraoperative errors that resulted in bile duct injuries. Early reports addressing the increasing rate of bile duct injury after cholecystectomy focused on methodical and well-visualized dissection of the gallbladder–cystic duct junction before clips are applied and any structure is cut. 40.

Approximately two thirds of reported bile duct injuries in both groups occurred below the bifurcation of the common bile ducts ( Table 3 ). Group B surgeons reported more injuries at the bifurcation of the bile ducts (15% vs. 7.6%, P ≤ .05), and these injuries were more commonly discovered after surgery ( Table 4 ). All other injury patterns were reported with similar frequency between groups. Regardless of group, more injuries below the bifurcation of the bile duct were identified during surgery than after surgery, and more strictures were identified after surgery than during surgery ( P < .05) In addition, more surgeons in group B reported identifying injuries during surgery than surgeons in group A (71% vs. 61%, P ≤ .05).

Intervention used to treat the injury.

Several studies have presented data that a minority of bile duct injuries (8% to 33%) referred to tertiary care centers have been recognized at the time of LC (32-36). Usually, unexplained bile drainage raises the suspicion of a biliary injury. In the case where a biliary injury is suspected, the surgeon must have the biliary anatomy cholangiographically, to avoid any additional dissection. This is imperative, otherwise further injury or devascularize the bile duct might occur (31). In several cases, it is necessary to perform an open procedure and identify biliary anatomy. In some cases, an injury is suspected after completion of the cholecystectomy from ongoing biliary drainage. In the case where an injury is confirmed by laparoscopic cholangiography and complex biliary reconstruction cannot be performed, several drains may be placed laparoscopically, and the patient transferred to a specialized hepatobiliary unit (31). There is the choice also a small red rubber catheter placement into an injured or transected bile duct which enables opacification of the biliary tract postoperatively. This method will assist in future attempts at the placement of a percutaneous transhepatic catheter. Moreover, a closed suction drain should be left in the subhepatic space. The best option for the patient would be that an experienced surgeon performing the LC will make an immediate repair and minimize the morbidity associated with the injury (32,37). Based on the operative findings the appropriate operative repair will take place. In the case where the transected duct is 4 mm or larger, then multiple drains will be placed in hepatic segments or the entire right or left lobe and should be repaired or re-implanted. In the case of ducts <3 mm then in can be safely ligated if cholangiography demonstrates filling of a single hepatic segment (31). T-tubes can be used in the case of partial transections of the bile duct from a separate choledochotomy. Furthermore, complete ductal transections include loss of some ductal length because of clip application or excision of a segment of the bile duct. It is known that the debridement of the transected end back to normal tissue will lead to loss of additional ductal length. Additionally, end-to-end ductal repairs are rarely achieved without some tension even with a further mobilization of the duodenum, however; a restructured rate approaching 100% has been reported (24). It has been reported that a tension-free biliary-enteric anastomosis to a Roux-en-Y jejunal limb achieves the best long-term results, and it is preferred in most cases (24,32). It is imperative that a Roux-en-Y limb is used compared to a choledochoduodenostomy because the latter may cause an anastomotic leak which will result in a duodenal fistula (31).

Submitted Mar 19, 2016. Accepted for publication Mar 24, 2016.

Transhepatic stents are useful technical aids which placed preoperatively to identify the hepatic ducts particularly (32,40). The technique requires that the bile duct is divided at the distal extent of the stricture, and afterwards the distal end is oversewn. The ductal segment containing the stricture is resected, and finally, an end-to-side hepaticojejunostomy is constructed over a silastic transhepatic stent. Afterwards, the transhepatic stents are finally left in postoperatively for several months.

In the majority of the patients, with a BDI will present within the first few weeks following LC (31,32). The main symptoms will be fever, pain, and mild hyperbilirubinemia (2.5 mg/dL) from a biloma or bile peritonitis. Usually, bile will be observed leaking externally from a drain or surgical incision. In the case of injuries involving occlusion of the common hepatic or bile duct without an intraperitoneal bile leak, the main symptoms will be jaundice with or without abdominal pain. In some cases, patients will present cholangitis or cirrhosis from a remote BDI at a later time probably months or years after biliary surgery (22). In severe early postoperative cases, patients will present with sepsis from cholangitis or intra-abdominal fluid collections. In the case of a suspected bile leak, ultrasound or and an abdominal computed tomography (CT) scan or will identify peritoneal fluid, biloma, or an abscess. In the case of perihepatic fluid collections, drainage can be applied percutaneously. Usually, broad-spectrum parenteral antibiotics covering the common biliary pathogens are initiated (31). When a percutaneous drainage is applied, and ongoing biliary drainage is observed then of active bile leak is verified. There is also the case where the diagnosis is confirmed noninvasively with a technetium iminodiacetic acid (Tc-IDA) scan. A sinogram can also be used after a fibrous tract has formed. In the case where there is no external bile leak, the biliary anatomy is defined with an endoscopic retrograde cholangiopancreatography (ERCP) (22). In the case of cystic duct bile leaks which are detected during ERC, the best management would be the placement of a biliary endoprosthesis and percutaneous drainage of any intra-abdominal fluid collection (22). The diagnostic evaluation is slightly different in a patient with jaundice and suspected BDI. There are two examinations usually performed, firstly a CT scan (abdomen) and secondly an ultrasound which will evaluate and demonstrate the presence of intrahepatic and extrahepatic ductal dilation. These two examinations will also provide some anatomic information regarding the level of the injury, if one segment or lobe is affected or whether the entire intrahepatic ductal system is involved. When an intrahepatic ductal dilation occurs from a biliary stricture, then percutaneous transhepatic cholangiography and placement of a transhepatic stent are necessary to decompress the biliary tree and relieve jaundice also by doing this the proximal extent of the injury will be defined. And appropriate treatment will be applied. It is necessary that the biliary anatomy is defined including all ductal segments as this information is the most important factor in the success of any operative repair (24). The so-called “isolated segments VI and VII” are suspected if these ducts aren’t visualized on cholangiography, and then a CT scan or magnetic resonance cholangiography should be performed (19,38). It has been observed that in the majority of the repairs performed without preoperative cholangiography (96%) or with incomplete cholangiography (69%) then success is reduced significantly (24). If complete cholangiography is performed then, surgical reconstruction has a success rate of up to 84% (24). If sepsis and biliary leak are controlled then there is no reason to rush to surgical repair of the bile duct stricture. Moreover, postoperative injuries are best managed with operative exploration and repair in 6 to 8 weeks after acute inflammation has resolved from the perihepatic bile leak (31,39). It is of the most importance that attention is given to fluids, acid-base balance and electrolytes during this interim period. The goal of surgical repair is a tension-free, mucosa-to-mucosa duct enteric anastomosis, which in the majority of the cases an end-to-side Roux-en-Y choledochojejunostomy or, more commonly, a Roux-en-Y hepaticojejunostomy is performed. There is the case where there are strictures involving the bifurcation or left or RHDs, and, therefore, bilateral hepaticojejunostomies may be necessary.

Type II includes the proximal CHD <2 cm from the junction. Type III is hilar injury with no residual CHD confluence intact. Type IV occurs when the right and left hepatic ducts become separate. Type V involves the aberrant right sectoral hepatic duct alone or with a concomitant injury of CHD. The major disadvantage of the Bismuth classification is that it does not include a broad range of biliary injuries.

Injuries recognized in the postoperative period.

The author Bektas et al. proposed a new classification system named which was named Hannover classification system. This classification system was introduced after observation of 72 iatrogenic bile injuries after LC. The Hannover classification system classifies bile duct injuries into five types from A to E (25). Type A is considered as peripheral bile leakage. Type B is found when stricture of CHD or CBD is observed without injury. Type C is considered when lateral CHD or CBD injury is found. Type D occurs when a total transaction of CHD is observed. Type E is considered when bile duct stricture of the main bile duct occurs without bile leakage at postoperative state. Moreover, vascular injuries are included in type C and type D classification. The Hannover classification was able to distinguish a total of 21 injury patterns in a small group of patients. The advantage of using the Hannover classification is that it makes an association between the discrimination of classifiable injury patterns and the appropriate surgical treatment. This Hannover classification provides discriminators for the localization of tangentially or entirely transected bile ducts in correlation with the bifurcation of the hepatic duct, which is the primary disadvantage of other classification systems.

Abstract: Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy (LC). Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries. Bile duct injury (BDI) is a severe and potentially life-threatening complication of LC. Several series have described a 0.5% to 0.6% incidence of BDI during LC. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.

Whereas the Strasberg classification is a modification of the Bismuth classification provides a differentiation between small and serious injuries during LC as type A to D. Type E of the Strasberg classification is considered an analog of the Bismuth classification (22). The Strasberg classification is very easily applied to bile duct injuries. The Strasberg classification does not describe additional vascular involvement and for this reason, it cannot demonstrate a significant discrimination for specific injury patterns ( Table 2 ).

It has been reported that patients with bile duct stricture or injury when operative repair was performed they have had excellent results at tertiary expert referral centers (32-36). In several series of operative repair the mortality observed was very low (0% to 3%). It has been observed that patients who had been scheduled for an elective procedure and short-term hospitalization had a high morbidity rate with complications such as; subhepatic or subphrenic abscess, cholangitis, bile leak, and hemobilia) both pre- and post-operatively. It has been observed that long-term follow-up is necessary to evaluate fully the results of biliary reconstruction for BDIs (41). Moreover, restenosis of a biliary-enteric anastomosis can occur many years following operative repair. Up to two-thirds of recurrences have been observed to become symptomatic within 2 years after repair. There have been cases of restenosis after 10 years after surgery (41). Lillemoe et al. (32) reviewed the long-term results of 89 patients with laparoscopic bile duct injuries managed at “The Johns Hopkins Hospital” and observed that 82 patients were referred from an outside institution and that the two-thirds of these patients had undergone at least one laparotomy and one attempted repair. It was observed that the majority (81%) of these patients was women, and their mean age was 41 years. The average time of interval from LC to referral was 7.7 months. The most frequent symptoms of presentation were obstructive jaundice (37%), ongoing biliary leak or fistula (38%), or cholangitis (22%) (32). In all cases, percutaneous cholangiography and biliary drainage were applied to control the bile leak and associated sepsis. Moreover, patients with a perihepatic fluid collection or a biloma also underwent percutaneous drainage for management. Additionally, the treatment of these patients included percutaneous balloon dilation and long-term stenting (n_28, all repaired previously elsewhere) or for most of them surgical biliary reconstruction (n_59). In this study, 25% of the patients had been managed operatively and they have had one prior attempt at operative repair, and only 8% of these injuries were initially recognized upon LC. The classification of these patients (61%) was Bismuth level 3, 4, or 5. In these patients, biliary reconstruction included of a Roux-en-Y hepaticojejunostomy over one or more transhepatic silastic stents. In this study, two-thirds of the patients were stented postoperatively for at least 9 months. There was a classification by the authors according to the result as follows: excellent (no symptoms), good (mild symptoms were not requiring treatment), or poor result (additional treatment). Moreover, the positive outcome was considered according to the first two groups 92% in total (excellent 79%, good 13%) with a mean follow-up of 33 months. It was observed that there were four treatment failures after surgical reconstruction which became symptomatic within 27 months of reconstruction (32). The main factors which influenced the outcome were again the type of stricture and the level of the stricture or injury. It was observed that proximal strictures had a lower success rate when compared with distal strictures. In general, when patients had an initial repair of their ductal injury a lower restenosis rate was observed than patients undergoing operative revision. According to the authors, the length of postoperative stenting had nothing to do with the outcome (32). Other authors such as Stewart-Way reported again as the previous authors that early treatment of BDI during LC results in favorable outcomes (88 patients) (24). Sixty-four of these patients were operated by a primary surgeon while 46 patients repaired at a tertiary referral center. In this study, several factors determined the success of the repair. Firstly, treatment failure was associated with incomplete preoperative cholangiography, secondly, Roux-en-Y hepaticojejunostomy was successful more than repairs for ductal transections. Moreover, attempts at repair by the primary surgeon were more likely to fail at the hospital primary care than repairs performed at tertiary referral centers. Again high success rates have been reported from centers when median follow-up was conducted (24). Complications are also associated with medical and financial costs. Savader et al. reviewed in his study the hospital course and charges related to the treatment of 49 patients with bile duct injuries. These patients underwent surgical repair at “The Johns Hopkins Hospital” (37). It was observed in this study that the early BDI recognition immediately at the time of LC had fewer days of hospitalization and less financial costs (37).

Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

McMahon et al. classified the injury by the width of BDI. In specific lacerations under 25% of the CBD diameter or cystic-CBD junction were classified as a minor injury. The transection or laceration of over 25% of CBD diameter and postoperative bile duct stricture are classified as major injury (23).

Bile duct strictures and biliary leakages are severe complications after cholecystectomy procedure. Biliary leakages are considered an early complication and biliary strictures are a late complication. It is observed that the rate of clinically-relevant bile leaks after conventional open cholecystectomy ranges was between 0.1% and 0.5% (1-3). Biliary leakages have increased after the development of laparoscopic cholecystectomy (LC) by up to 3% (4-7). Therefore the surgical management of bile duct lesions is afterward required to resolve this issue. However, surgical management has been associated with high mortality and morbidity (8,9). Endoscopic procedures are nowadays mostly used in the management of postoperative bile duct injuries. There are several endoscopic techniques such as biliary stent placement, biliary sphincterotomy, and nasobiliary drainage (10-12). It has been observed that endoscopic therapy can reduce the transpapillary pressure gradient. Moreover, during endoscopic procedures the transpapillary flow is improved and as an additional effect, the extravasation out of the biliary tract is reduced. It has been observed that the healing of bile duct lesions is quicker facilitated during the insertion of a transpapillary endoprosthesis or a nasobiliary drainage. We do not have a long-term follow-up for the endoscopic treatment of bile duct injury (BDI), including leakages and strictures, however; endoscopic procedures are considered to be safe and efficient. It is known that gallstone disease is a common digestive health problem (13). LC is now the golden standard for gallbladder removal in the management of symptomatic cholelithiasis; it has a decreased postoperative mortality and morbidity. However, it has been observed that bile duct injuries are more severe and common when compared to open cholecystectomy (14-17). There is a report where the incidence of biliary tract injuries was found to be up to 0.6% for laparoscopic versus 0.1% for open cholecystectomy (17). These injuries lead to high morbidity, mortality, and prolonged hospitalization (18). If major bile duct injury (MBDI) occurs, then it requires a skilled and experienced hepatobiliary surgeon at a tertiary referral center (19). Collaboration with surgeons, interventional radiologists and gastroenterologists is usually necessary for the care of such injuries. We are going to present the classifications of bile duct injuries the application of surgical treatment (when needed) and the timing of the application of surgical treatment.

According to Stewart-Way classification, there are four types (24). Class I injury occurs when CBD is mistaken for the cystic duct, and the error is recognized before CBD is divided. Class II injuries are done by damage to CHD from clips or cautery. These kinds of damages occur in cases where visibility is limited due to bleeding or inflammation. Class III injury, which is the most common type, occurs when CBD is mistaken for the cystic duct. There three cases the first where the common duct is transected, the second which includes the junction of the cystic and the third where the common duct is excised or removed. Class IV injuries involve damage to the right hepatic duct (RHD), there are two main causes the first this structure is mistaken for the cystic duct, and the second because it is injured during dissection. In the Stewart-Way classification both complex bile duct and vascular injuries are included.

Currently, the classification is based on peripheral leakages, central leakages, and biliary strictures. Siewert et al. (20) described type 1 lesions which are peripheral leakages and include immediate biliary fistulas. On the other hand, central leakages consist of tangential lesions without structural loss of the bile duct and correspond with type 3 lesions (20). Type 2 is lesions occur when biliary strictures comprehend late strictures without obvious intraoperative trauma (20). Tables 1 and 2 present the Corlette-Bismuth classification and Strasberg classification under radiographic guidance using contrast fluid, biliary leakages and bile duct strictures.

MBDI after LC requires a multidisciplinary approach with specialized physicians at tertiary hospitals. Imaging techniques and proper classification is required in order to prevent or treat sepsis, biliary leaks, and collections. Roux-en-Y hepaticojejunostomy should be considered in these cases, since it presents excellent results. In some cases, life-threatening complications can occur if the referral to an expert center is delayed or, rarely, after surgical repair. It has been observed that complications are frequent, however; almost all can be managed non-operatively.

Bismuth classification.

The most common BIs include biliary leakage, biliary fistula, and hemobiliary. There have been several proposals recently to classify postoperative strictures and bile duct injuries. The Corlette-Bismuth classification made a proposal which is based on the length of the proximal biliary stump, however; not on the nature and length of the lesion. McMahon has proposed a detailed subdivision into minor and major bile duct injuries. Minor injuries are considered when laceration of the cystic to CBD junction and laceration of the CHD is <25% of the duct diameter. Major injuries are considered when laceration is >25% of the bile duct diameter, also, if transection either of the common hepatic or CBD occurs or if there is a development of postoperative stricture. There is also the Strasberg classification which is considered the most detailed classification as it includes all types of injuries (15). Unfortunately, it is almost impossible to obtain the exact incidence rate of iatrogenic bile duct injuries because bile duct injuries could be attributed to the negligence of surgeons or anatomical abnormalities or even agenesis of the gallbladder (42). When a MBDI after LC occurs it is difficult to treat the problem and depends on the time of diagnosis after the initial injury and the type, extent and level of the injury. Immediate management is necessary to avoid fistulas, sepsis, and obstruction of the biliary system. MBDI identification and categorization of the type is necessary in order to identify the next steps. After classification, repair of the injury should be performed. There should be a postoperative follow-up, and a prolonged treatment protocol is necessary. Furthermore it has been reported that the incidence of MBDI after LC is higher than that after open cholecystectomy (43). There are risk factors such as; dangerous anatomy, dangerous pathology, and dangerous surgery (44). There is a great chance that MBDI is missed during LC (32). There are anatomical structure variations of Calot’s triangle which are not very clear because of congestion, edema, and fragility of the tissues surrounding the cystic duct in acute suppurative or gangrenous cholecystitis. Therefore, the exposure of peritoneal attachments in Calot’s triangle is necessary in order to identify anatomical variations, and the cystic duct should not be separated at the junction of the common hepatic, and cystic ducts are positively identified. In some cases, fibrous tissue scars are identified in Calot’s triangle in atrophic cholecystitis. Nowadays injuries to the bile duct system during LC are not associated only with the experience of the surgeon and is also not related to the “learning curve” of the operating surgeon as suggested in the past (45). Recent studies demonstrated that the in one-third of all bile duct injuries, the basic cause use of a nonproper approach to the fundamental structures of the extrahepatic biliary tree. In specific because of a visual perceptual illusion (45). Another issue is inflammation or chronic fibrosis at the time of the initial procedure which does not allow the proper evaluation of the situation. Currently, the role or use of Intraoperative laparoscopic ultrasonography and cholangiography in prevention of MBDI during LC is a matter of ongoing debate (46). Upon referral, all patients with suspected BDI should undergo Ultrasound and CT of the abdomen so that any dilatation of the bile duct system or fluid collection can be observed. In most cases those techniques must be combined with magnetic resonance cholangiopancreatographies (MRCP), ERCP or even percutaneous transhepatic catheterizations (PTC) in order to identify the biliary anatomy (15). In cases where patients do not recover after cholecystectomy then these patients are considered candidates for having a BDI. In the case of BDI the patient should be transferred to a tertiary care center with expertise in biliary surgery, by doing this we limit further operations, complications, time to definitive repair, and finally mortality. Moreover, pre-operative imaging studies such as MRCP, ERCP, and PTC also correctly identify all necessary information regarding MBDI (15,47). Surgery treatment should be performed only when the patient is stabilized and the MBDI has been properly classified because the success of the operating procedure depends on the proper and accurate identification of the MBDI. In the case of the early postoperative period (2 to 7 days), which involves a relatively distal lesion below the bifurcation and there is no biliary leakage, sepsis or abscess formation then early reconstruction can be considered. In the case of bifurcation, then percutaneous biliary drainage is preferred with an elective repair after 6 to 8 weeks (15). The control of sepsis with antibiotics and proper fluid balance should be considered the primary goals of the initial management of BDI. If the patient is stable and the appropriate care is provided then proceeding with surgical reconstruction is not considered urgent.

Keywords: Biliary tract; laparoscopic cholecystectomy (LC); hepatobiliary surgeons.

H. Bismuth in 1982 is the first to create a classification. Since then many groups have provided additional classifications (see below). The Bismuth classification is based on the location of the injury in the biliary tract. This classification includes five types of bile duct injuries according to the distance from the hilar structure especially bile duct bifurcation, the involvement of bile duct bifurcation, the level of injury, and individual right sectoral duct (21). Type I involves the common bile duct (CBD) and low common hepatic duct (CHD) >2 cm from the hepatic duct confluence.

Moreover, when sepsis and leaks are controlled, and the MBDI is classified, and then a hepaticojejunostomy should be modified to a Roux-en-Y jejunal limb, or less commonly an end to side Roux-en-Y choledochojejunostomy. Also, in some cases, the technique of Roux-en-Y hepaticojejunostomy has been proposed. In the cases of strictures involving the bifurcation of left or RHDs, bilateral hepaticojejunostomies may be necessary. Association of the level of injury and the outcome of the surgical procedure has been proposed. There are also other factors that foresee the surgical outcome such as; the performance of preoperative cholangiography, include the timing of the repair, the expertise of the surgeon performing the repair, the choice of surgical procedure, and the presence of concomitant vascular injury (32). It has been reported in the literature that the outcome of surgical reconstruction for major lesions or failure of endoscopic treatment depends on the timing of the reconstruction (15). It is proposed that postoperatively the transhepatic catheters should stay for external gravity drainage until day 5, and a cholangiogram should be performed. It is also proposed that upon follow-up cholangiograms should be obtained at 1 month and 3 months postoperatively, if necessary, more often or earlier. Moreover, catheters should be removed between 3 and 6 months postoperatively, this depends on the level of the injury, as well as the appearance of the cholangiogram (43). Recurrent biliary stricture has been observed in 10–30% of cases, after open cholecystectomy (48). It has been also noted that patients with recurrent stricture develop more frequently restenosis. Additionally, previous surgical attempts also greatly influence the outcome, because repeated attempts make the stricture even greater, leading to an even more challenging next repair and the result not always favorable.

When biliary tract injuries occur, surgical treatment has to be applied. The time of diagnosis after the initial injury and classification (which includes the extent and level of the injury) is critical for optimal treatment. There are several injuries which can create short- and long-term complications (intra-abdominal fluid collections and biliary fistula or abscess, biliary or anastomotic strictures, biliary cirrhosis and cholangitis) (31,32).

Another classification system has also been created, called the Mattox classification of BDI which takes into consideration the types of injuring factors (laceration, contusion, transection, perforation, diversion or interruption of the bile duct) (26). There are also other several classifications for induced BDI during LC (27-30).

Conflicts of Interest: The authors have no conflicts of interest to declare.