IATROGENIC

BILE DUCT INJURY

Moderator – Dr Isha Dahal

Presenter – Dr Jitendra Singh
MS General Surgery
NAMS, Bir Hospital
Anatomy
T- tube cholangiogram shows the most common arrangement of hepatic ducts
 Trans tubal cholangiogram

common normal variant: right

posterior sectional duct drains
Biliary and vascular anatomy of the right liver into left hepatic duct
horizontal course of the posterior sectional duct

vertical course of the anterior sectional duct

posterior duct is anterior to posterior
sectional duct
Frequently in this variant, posterior
duct passes posteriorly to anterior
sectional pedicle
Endoscopic retrograde choledochopancreatogram
showing pancreatic duct (arrow), gallbladder, and
biliary tree
 Anatomy of plate system

Umbilical plate, above umbilical portion of portal vein

Hilar plate, above biliary confluence

& at base of segment IV

Cystic plate, above the gallbladder

Plane of dissection of hilar
plate during approaches to
left hepatic duct

plane of dissection of
cystic plate during
cholecystectomy
 The bile duct blood supply

Hilar ducts
surrounding vessels  rich network on surface of
RHD and LHD in continuity with plexus around
left branch of hepatic artery
supraduodenal duct
right branch of the hepatic artery
Eight small arteries, each 0.3 mm
in diameter
hepatic artery 60% vessels run upward from
axial arrangement of vasculature of supra major inferior vessels, & only
38% of arteries run downward
duodenal portion of main bile duct
2% of arterial supply- nonaxial,
9 o’clock artery 3 o’clock artery (from main trunk of hepatic
artery)
common hepatic artery
retro duodenal artery
 Mural plexus gastroduodenal artery

Retropancreatic CBD
 Lymphatic drainage

Liver
 hepatoduodenal nodes at hilus and along
hepatic artery and portal vein

Gallbladder
partly to liver,
cystic node  nodes of hepatoduodenal
ligament  suprapancreatic nodes
 Nerve supply

Distribution of sympathetic and

parasympathetic nerves to liver and
pancreas from celiac ganglion, mainly
in association with major arteries
 Main variations in gallbladder and cystic duct anatomy

A. Duplicated gallbladder

B. Septum of gallbladder

C. Diverticulum of gallbladder

D. Variations in cystic ductal anatomy

E. Different types of union of the cystic

duct and common hepatic duct:
a) angular union
b) parallel union
c) spiral union
Variations of ectopic drainage of intrahepatic ducts into gallbladder and cystic duct

A. Drainage of cystic duct into biliary confluence

B. cystic duct into left hepatic duct, associated with
no biliary confluence.
C. segment VI duct into cystic duct

D. right posterior (RP) sectional duct into cystic duct

E. distal part of right posterior sectional duct into

neck of gallbladder

F. proximal part of right posterior sectional duct into

body of gallbladder
 Variations of hepatic duct confluence

A. Typical anatomy of confluence

B. Triple confluence

C. Ectopic drainage of a right sectional duct into CHD

• C1, Right anterior (ra) duct draining into CHD
• C2, rp duct into CHD

D. Ectopic drainage of a right sectional duct into left hepatic

ductal system.
• D1, Right posterior sectional duct draining into left
hepatic (lh) ductal system
• D2, right anterior sectional duct draining into left
hepatic ductal system.

E. Absence of hepatic duct confluence

F. Absence of right hepatic duct and ectopic drainage of

right posterior duct into cystic duct
 Variations of cystic artery

a) typical course
b) double cystic artery
c) cystic artery crossing anterior to
main bile duct

d) originating from right branch of

hepatic artery and crossing CHD
anteriorly
e) originating from left branch of
hepatic artery
f) originating from GDA

g) arising from the celiac axis

h) originating from a replaced right
hepatic artery
 BDI
• Laparoscopic cholecystectomy (LC): gold standard operation for patients with gallstone disease
and represents one of most common routine interventions performed worldwide in both elective
and emergency settings
• Devastating for both surgeons and patient
• Affect the prestige and lead to litigation for surgeon
• Increases morbidity and mortality of the patient

• BDI Incidence
• laparoscopy (0.4–1.5% of cases)
• open cholecystectomy (0.2–0.3% of cases)
• Since early reports, the frequency of BDIs during LC has been progressively decreasing.
 Causes of iatrogenic BDI

1. Laparoscopic cholecystectomy
2. Nontraditional Cholecystectomy
1. Natural orifice translumenal endoscopic surgery (NOTES)—a technique to obtain intraabdominal access via
transgastric, transvaginal, transvesical, or transcolonic routes
2. single-incision laparosopic surgery (SILS) to perform cholecystectomy via a single port at the umbilicus
3. Biliary Reconstructive Operation - after pancreaticoduodenectomy, bile duct resection for mid–bile duct
tumors, and excision of choledochal cysts
4. Open Cholecystectomy
5. Common Duct Exploration
6. Liver Resection
7. other abdominal operations requiring dissection in or near porta hepatis
• gastrectomy with or without lymphadenectomy
 Pathogenesis/Mechanism/Risk factors of BDI

right posterior sectoral hepatic

Anatomic Variations
• Cystic duct insertion
• Low entry of right posterior
sectoral hepatic duct
• Toutuous course of rt hepatic
artery (Moynihan’s/caterpillar
hump)
duct (black arrow) joins a main
left hepatic duct
Cholecystectomy was accompanied by
a biliary injury at point of confluence
of CHD and right anterior sectoral
hepatic duct (Bismuth type 5)

right anterior Repair by Roux-en-Y

sectoral hepatic hepaticojejunostomy done
duct drains into
CHD
 Biliary Ischemia

• Extensive circumferential dissection of duct (extensive periductal

dissection)  disrupt axial blood flow  biliary stricture
• Do not to pursue extensive dissection of common duct during
cholecystectomy; avoid electrocautery use
 Pathologic Factors
Acute cholecystitis, cholangitis, gallstone pancreatitis
• severe inflammation in porta hepatis and triangle of Calot - distorts anatomy
• gallbladder is distended, friable, and difficult to grasp, and persistent oozing of blood

severe inflammatory reaction /heavily fibrosed cases

• Fibrosis and inflammation within triangle of Calot - cystic duct dissection is
hazardous
• gallbladder neck and cystic duct may be fused to common duct  distort base of
cystic plate within a sheath of scar tissue  extensive dissection to define cystic duct
 major biliary injury
Options:
• Cholecystostomy
• Partial (subtotal) cholecystectomy with amputation of gallbladder, well away from
cystic duct/ common hepatic duct junction, + placement of a drain
• cystic duct is nearly always obliterated, and postoperative biliary leak is infrequent
 Technical Factors

Proper exposure, trochar placement, and modern high-resolution video

equipment

Traction on the gallbladder during cholecystectomy

• Escessive - tent common duct upward - risk of injury
Maximum cephalad traction on gb fundus with concomitant lateral traction on infundibulum
to expose cystic duct and triangle of Calot - angle between cystic and common hepatic ducts

Upward traction Upward traction on

gallbladder
on gallbladder

Proper lateral Opens Calot’s triangle

traction on
CD and CHD become infundibulum
aligned within same
plane
SAFER DISSECTION OF CD
Plane of dissection should be maintained as close to gb wall as possible
to avoid entering liver parenchyma through cystic plate
• Straying off the gallbladder wall 
• entry into liver parenchyma  bleeding  further obscuring the field
• injury to a low-entry sectoral hepatic duct or a replaced right hepatic artery
• major right portal pedicles and branches of middle hepatic vein may be quite superficial in liver substance with
respect to GB fossa --damage if plane of dissection too deep

Calot’s triangle: must be cleared of all fatty and areolar tissue before any
structures are divided

Strasberg “critical view of safety” (1995)

• use of a 30-degree laparoscope has been advocated to improve visualization
Bleeding and subsequent attempts to achieve hemostasis
• If needed, an additional 5-mm port can be used for a high-powered suction/ irrigator to help
define the site of bleeding
• Avoid blind placement of clips or indiscriminate use of electrocautery
Use of clips: Tips of clip should meet
• Clip dislodgement; migration; incomplete occlusion
• If clip does not fit across entire width of CD - possibility of structure about to be divided is not CD but
common duct

Electrocautery in areas adjacent to clips should be avoided

• conduction of thermal energy to adjacent common duct  delayed biliary structure

Cystic duct should be divided as close as possible to its junction with GB

Observation of bile draining from gallbladder fossa always suggests possibility of a biliary injury,
perhaps to an aberrant right sectoral hepatic duct

Intraoperative cholangiography(IOC) during cholecystectomy: controversial

• very small CBD with a small stone
• simple cholecystectomy without exploration of common duct
• Postoperative endoscopic cholangiography with stone extraction if subsequently indicated
• exploration of a small caliber, otherwise normal-appearing common duct -- Biliary strictures
• Exploration of the CBD, if carried out, must be gentle and performed only with soft bougies, Fogarty-type balloon
catheters, or a choledochoscope

Mistaking common duct for cystic duct

“classic” laparoscopic injury
may be associated with damage to right hepatic artery
 CLASSIFICATION OF BILE DUCT INJURY

Bismuth Classification (1982)

• Classification of postoperative bile duct STRICTURES based on location with respect to
hepatic duct confluence
• or involvement of an aberrant right sectoral hepatic duct with or without a
concomitant hepatic duct stricture (type 5)
• Adresses injuries that commonly occurred in open cholecystectomy era i.e., extrahepatic
bile duct injury
E1 (Bismuth type 1) - Injury more than 2 cm from
confluence

E2 (Bismuth type 2) - Injury less than 2 cm from

confluence

E3 (Bismuth type 3) - Injury at the confluence; confluence intact

E4 (Bismuth type 4) - Destruction of the biliary
confluence

E5 (Bismuth type 5) - Injury to aberrant right

sectoral hepatic duct alone or with concomitant
injury of CHD
Limitations:

• does not encompass entire spectrum of injuries that are possible

• biliary leaks

• major ductal injuries without stricture

• In an effort to fill this gap, Strasberg and colleagues (1995) proposed a comprehensive
classification system that incorporates Bismuth’s scheme but is much broader in scope
 Strasberg classification (1995)

A
BILE LEAKS FROM MINOR DUCTS STILL IN
CONTINUITY WITH CBD

MCC of biliary leaks seen after laparoscopic

cholecystectomy

leakage from cystic duct and from a subvesical duct

of Luschka
subvesical duct of Lushka = slender, 1- to 2-mm in
diameter duct, passes from right lobe in gallbladder fossa
to join right hepatic or common hepatic duct (McMahon
et al, 1995)
 B
OCCLUSION OF PART OF BILIARY TREE

which for practical purposes almost always is an

aberrant right sectoral hepatic duct

Aberrant right hepatic duct (ARHD) is branch providing

biliary drainage to variable portion of right hepatic lobe and
drains directly into extrahepatic biliary tree
 C
aberrant right sectoral hepatic duct is transected
without ligation,
 D
LATERAL INJURY TO AN EXTRAHEPATIC BILE DUCT

Similar to type A injuries in that the extrahepatic biliary

tree remains in continuity

but is classified separately to underscore greater severity

and potential need for major reconstruction
Biliary strictures further subdivided as E1 to E5 according to Bismuth classification
 Clinically

Minor BDIs
• injuries c/b electrocautery burns

• partial cut from sharp dissection with shears

• not associated with tissue loss

• repaired primarily with sutures + abdominal drains in the area

Major BDIs (i.e., Strasberg E)

• tissue loss (e.g., CBD is clipped and transected)

• require complex reconstruction with a Roux-en-Y hepaticojejunostomy

 ATOM (Anatomic, Time Of Detection, Mechanism) 2013
the all-inclusive, nominal EAES classification of BDI during cholecystectomy

O D mechanical,
energy driven

loss of
substance

main biliary duct

nonmain biliary duct

(Luschka duct,
aberrant duct,
accessory duct)
For each injury, surgeon fills in the following matrix: (1) single injury (yes/no); (2) multiple injuries (yes/no). Then one matrix is
filled in for each injury, as appropriate.
For example= injury made by an energy-driven (ultrasonic) dissector involving the superior biliary confluence
with interruption of the right and left hepatic ducts, detected (intraoperatively) during the operation by the
presence of bile
MBD 4 OC VBI Ei, ED.
• Standardization and transformation of BDI definitions into a unified language

• Data for epidemiological and comparative studies,

• true incidence of BDI during LC

• development of preventive measures

• Drawback: complex and time consuming

SAGES 6 SUGGESTED STRATEGIES SURGEONS CAN EMPLOY TO ADOPT A UNIVERSAL
CULTURE OF SAFETY FOR CHOLECYSTECTOMY TO AND MINIMIZE THE RISK OF BILE DUCT INJURY

1. Use the Critical View of Safety (CVS) method of identification of the cystic
duct and cystic artery during laparoscopic cholecystectomy
• criteria are required to achieve CVS:
i. The hepatocystic triangle is cleared of fat and fibrous tissue.
ii. The lower one third of the gallbladder is separated from the liver to expose the cystic plate. 
iii. Two and only two structures should be seen entering the gallbladder.
CVS can be confirmed using a Doublet View: has two components

Visualization of Visualization of the

the doublet doublet view (posterior)
view (anterior)
2. Understand the potential for aberrant anatomy in all cases.
• short cystic duct, aberrant hepatic ducts, or a right hepatic artery that crosses anterior to the common bile duct

3. Make liberal use of cholangiography or other methods to image the biliary tree
intraoperatively.
• If difficult cases or unclear anatomy

4. Consider an Intra-operative Momentary Pause during laparoscopic cholecystectomy prior

to clipping, cutting or transecting any ductal structures.
• to confirm that the CVS has been achieved utilizing the Doublet View.
5. Recognize when the dissection is approaching a zone of significant risk and halt the
dissection before entering the zone. Finish the operation by a safe method other than
cholecystectomy if conditions around the gallbladder are too dangerous.
• zone of  significant risk = failure to obtain adequate exposure of anatomy of hepatocystic triangle  or
dissection is not progressing due to bleeding, inflammation or fibrosis
• Consider laparoscopic subtotal cholecystectomy or cholecystostomy tube placement, and/or conversion
to an open procedure based on the judgment of attending surgeon

6. Get help from another surgeon when the dissection or conditions are difficult.
 Clinical presentation
• Most frequent complaints of patients with BDI are persistent abdominal pain, abdominal distension, nausea
and/or vomiting, fever, and jaundice
• Clinical presentations are related to type of injury

clinical scenarios:
• Bile leak
• bile from drain or surgical incision
• If subhepatic region is not drained -- perihepatic bile collection (biloma), abscess, or biliary peritonitis
• Generally, jaundice is not observed or is mild -- because cholestasis does not occur

• Biliary strictures,
• symptoms are often delayed
• Cholestatic jaundice: choluria, fecal acholia, and pruritus
• cholangitis
• Sepsis and multiorgan failure
 Pathologic Consequences of BDI

FIBROSIS
• Benign Biliary obstruction 
• high local concentrations of bile salts at canalicular membrane  initiate pathologic changes in liver
• Bile thrombi form within dilated centrilobular bile canaliculi, and secondary changes develop in
adjacent hepatocytes

• complex cascade of molecular and cellular events ensues = fibrogenesis

• deposition of collagen and other extracellular matrix proteins  fibrosis and scarring around bile
ducts and ductules

• process progresses  mechanical interference with bile flow in intrahepatic biliary radicles 
cholestasis
• preservation of the basic hepatic architecture,
• Fibrosis is accompanied by liver cell hperplasia
• *true cirrhosis  destruction of basic hepatic
architecture (very rare)
• many of pathologic changes are reversible
• histologic return of normal liver parenchyma is seen
after relief of obstruction
• return to near-normal liver function after relief of biliary
obstruction
ATROPHY
(Unilobar atrophy is a/w hypertrophy of c/l lobe)
Mechanism =
• distribution of liver mass is regulated by a poorly understood balance of bile flow, portal venous inflow,
and hepatic venous outflow
• Segmental or lobar atrophy  portal venous obstruction or bile duct occlusion

Dilated ducts within atrophic segments - filled with infected bile and debris
• drainage of an atrophic and hypertrophic segment is important
• Because cholangitis may continue unabated unless satisfactory drainage

Rotational deformity and anatomic distortioninfluences approach to repair Anastomosis in

region of hilum is difficult  thoracoabdominal approach may be necessary
PORTAL HYPERTENSION
• approx 15% to 20% of patients with benign biliary stricture have concomitant portal
hypertension
• Mechanism
• hepatic fibrosis
• direct damage to portal vein
• preexisting liver disease

• biliary strictures + portal hypertension –outcome is much worse, with in-hospital

mortality rate of 25% to 40%
• adequate biliary drainage  some resolution of fibrosis & reduction in portal pressure
 IMAGING
(for Post cholecystectomy BDI)

Imaging studies play a central role in assessing patients with biliary injuries and
should be directed at answering following questions:
• Is there a bile collection or abscess?
• Is there ongoing bile leakage?
• What is the level and extent of injury in the biliary tree (BDI)?
• Are there associated vascular injuries?
• Is there evidence of lobar atrophy?

Helps to Plan appropriate intervention

Duplex ultrasonography
• excellent, noninvasive
• Intrabdominal fluid collection, dilation of biliary ducts, associated vascular lesions
• it is of little value in assessing extent of a stricture and is of no value if biliary tree is
decompressed
 Abdominal triphasic CT scanning:
• best initial study
• presence of focal intra- or perihepatic fluid collections
• ascites
• biliary obstruction with upstream dilation
• long-term sequelae of a longstanding bile stricture,
• lobar hepatic atrophy
• signs of secondary biliary cirrhosis
• associated vascular lesions, such as injury to right hepatic artery
Limitations:

• Can not reliably distinguish bile leaks from other post op fluid collections, such as blood, pus, or
serous fluid, because of their similar densities.

• can not precise location or active state of a bile leak

• bile collection site may not be separate from leak site and occasionally may even be
intrahepatic
 ERCP

• Persistent bile leak after percutaneous drainage– to diagnose and treat

• incomplete strictures (stenoses)

• history of sphincteric damage at previous common duct exploration,

• suspicion of papillary stenosis or other periampullary pathology

After percutaneous
drainage of biloma
patient was
evaluated by ERCP

Arrowhead- contrast
extravasation
Duct of
Luschka
After transection of bile duct, an ERCP was
undertaken with deployment of biliary stents.

Contrast is noted to extravagate from blind end

at site of transection (arrow)
 PTC

• Level and extent of injury in pts with biliary stricture

• Extraluminal percutaneous endoscopic rendezvous procedure
• stent placement to restore continuity of bile duct

• Preoperative PTC and catheter placement if

complex injury/ severely distorted anatomy d/t atrophy, hypertrophy, or dense scarring
• additional cholangiographic information
• intraoperative guidance palpation of catheter intraoperatively can help guide identification of ductal
structures during definitive repair
• catheters can be easily exchanged for soft tubing to stent across worrisome small caliber anastomoses
ERCP and PTC complications/Disadvantages:
i. invasive techniques
ii. severe acute pancreatitis (mainly after ERCP)
iii. bleeding
iv. cholangitis (after PTC)
v. lack of detection of extrabiliary abnormalities and non visualization of ducts
upstream or downstream from an obstructing lesion (e.g., stricture, stone)
vi. PTC can be technically difficult because intrahepatic bile ducts are usually not dilated
 Magnetic resonance cholangiopancreatography (MRCP)

• “Gold standard” for a complete morphological evaluation of the biliary tree

• Noninvasive, does not use ionizing radiation
• Provides excellent anatomical information regarding biliary tree anatomy
proximal and distal to the level of injury

• CE-MRCP after hepato-specific contrast agent injection

• gadoliniumethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOBDTPA)
• improves accuracy of bile anatomy depiction and bile leak detection
A large biloma is visible

Contrast is noted to terminate

abruptly in the bile duct at the
surgical clip (arrow)
 Isotopic scanning techniques: HIDA
scanning/ Biliary Scintigraphy

• Injection of Iminodiacetic acid, which is processed in liver and

secreted with bile, allows identification of bile flow
• Assessment of
1) liver function
2) flow/clearance of bile across anastomoses and stenoses
• follow-up of patients after surgical repair(biliary reconstruction)
• anastomotic patency and function when no tube has been left across anastomosis at time of
repair
3) isolated sectoral hepatic duct stricture
• delayed clearance of isotope from a portion of liver
4) identify relationship between leak and any fluid collection
HIDA several days after biliary injury
After 60 minutes, there is an obvious biloma.
Arteriography and delayed-phase portography
• to assess for vascular injury
• combination of biliary and vascular injuries
• patients are at increased risk for severe complications, s/a hepatic necrosis
and abscess, after reconstructive surgery
• biliary reconstruction in setting of hepatic artery occlusion -- greater risk of
late stricture recurrence
 Preoperative Preparation
• Operative repair of bile duct injuries need not be rushed, exceptions:
a. treatment of bile duct injuries recognized at time of initial cholecystectomy
b. emergency treatment of suppurative cholangitis or peritonitis

• Treatment of Cholangitis
• IV antibiotics
• severe cholangitis and sepsis -- percutaneous drainage before surgery

• Management of biliary peritonitis, or hepatic failure secondary to fibrosis

• Drainage of intraabdominal abscesses and control of GI hemorrhage
• Anemia correction
• Coagulation defects - vitamin K or fresh frozen plasma
• Malnutrition
• Enteral feedings and parenteral nutritio
• fluid deficits and electrolyte imbalances
• significant external bile fistula  excessive fluid and electrolyte loss  hyponatremia and
acidosis
• Management of portal hypertension and external bile fistula occurring in
association with stricture
 Surgical
Treatment

(A–D and conditionally E2) (E) a/w tissue loss & ischemic injury suspected

T-tube at a healthy region of CBD, either proximal or distal to

injury, to decrease incidence of future stricture formation
 If the surgeon cannot perform a reasonable repair and
experienced help is unavailable

Place drain in RUQ  refer

Benefits of early referral to a tertiary center,
a) specialized hepatobiliary surgeons and radiologists diagnose and treat biliary complications in a timely
fashion
b) Each failed repair is associated with some loss of bile duct length and greatly exacerbates an already
difficult situation
c) Durable reestablishment of biliary-enteric continuity is difficult when ducts are small and decompressed
d) Dissecttion in hilum make subsequent reconstruction more difficult or cause further biliary or vascular
injury

E.g., injuries involving biliary confluence  failure of initial repair and loss of bile duct length  isolation of
right and left hepatic ducts  repair becomes more difficult, and likelihood of a successful outcome is
reduced
 HPB experience is available

Abandon Laparoscopic approach in favor of a generous right subcostal,

extended subcostal, or chevron incision

Initial repair of damage recognized at time of cholecystectomy have two basic

aims:
1. maintenance of ductal length below hilus without sacrifice of tissue
2. avoidance of uncontrolled postoperative bile leakage and preventing fistula

Initial intervention may not be final definitive reconstruction eg. injury to small
ducts that may be difficult to repair
 minor BDI:

Injury to the lateral duct wall  direct suture repair

small and simple lacerations  repair with interrupted 4-0 or 5-0 absorbable suture

T-tubes
• probably unnecessary for small lacerations
• placement into a decompressed bile duct may exacerbate the injury (Rossi & Tsao, 1994)
• analogous situation = primary choledochorrhaphy after CBD exploration excellent results without using T-tubes

Long, lateral injuries that are not circumferential

• may be impossible to repair transversely without compromising the lumen
• direct repair over a T-tube is likely to result in future stenosis
1. vein patches may be used to cover such defects
2. cystic duct stump
3. pedicled flaps of jejunum
4. Roux-en-Y loop of jejunum as a serosal patch
 major BDI:

Complete duct transection

End to end repair
• if transected ends can be apposed without tension
• Which usually requires full mobilization of duodenum and head of pancreas

• anastomosis : single layer of interrupted absorbable sutures

• T-tube brought away from anastomotic line
• Silk sutures avoided for all biliary reconstructions -- promote an inflammatory reaction and act as a nidus for stone
formation

• high incidence of late stricture formation

• some support the use of end-to-end repair because more than two thirds of the associated complications, s/a stricture
or leak, can be managed nonoperatively

Roux-en-Y hepaticojejunostomy is recommended

 concomitant vascular injury:

• hepatic blood supply is mainly carried by portal vein interruption of right branch of hepatic artery

alone is usually well tolerated

• immediate repair of right hepatic artery is not the most frequent option even in tertiary care centers,
• low rate of injury recognition

• high level of technical expertise required

• efficacy of arterial reconstruction remains questionable

• low number of patients affected by symptomatic liver ischemia

• no occurrence of liver infarction and uneventful follow-up

• extensive imaging workup with a contrast-enhanced CT scan is mandatory prior to attempting the vascular repair
 Minor BDI:
keep the patient well nourished and free of infection

Avoid early reoperation: until biliary leak has been controlled completely and pt fully
resuscitated
During early injury:
• biliary tree is decompressed
• proximal ducts are small in caliber
• bile ducts deeply bile stained, and friable
• significant inflammation

Adequate repair requires exposing healthy bile duct mucosa within a sufficiently dilated
proximal duct to allow precise anastomosis Immediate surgical treatment is difficult and
seldom possible
Non operative management
• Low output bile leak from drain(<300ml/day)
• Usually resolves < 5-7 days
ERCP
i. High output from drain(>300ml/day)
ii. Percutaneous drain placement for bile collection on imaging  high output from drain
iii. Jaundice
iv. Continued Low output drainage for more than 5-7 days (persistent bile leak on imaging)

On ERCP
• Duct of Luscha  sphincterotomy
• Cystic duct stump leak  stent +/- shphicterotomy
• Suspected CBD injury 
• PTC to delineate anatomy
• Control drainage
• Plan repair by HPB surgeon

Success more likely if

• injury to duct is < 5 mm
• injury is extrahepatic
• no associated abscess or bilomaa
 Major BDI:
Initial approach:
• establish external bile drainage,
• control sepsis,
• treat other coexisting conditions that are life threatening

Principles of surgical management of late bile duct strictures :

i. Exposure of healthy proximal bile ducts draining all areas of liver
ii. Preparation of a suitable segment of distal mucosa for anastomosis
iii. Creation of a mucosa-to-mucosa sutured anastomosis of bile ducts to distal conduit, which is
almost always a Roux-en-Y loop of jejunum
 BILIARY-ENTERIC REPAIR

Bile duct transection or stricture

CHOLEDOCHODUODENOSTOMY
• Ideal procedure for strictures of retropancreatic or immediate supraduodenal
portion of CBD
E.g., post gastrectomy strictures
• side-to-side or end-to-side anastomosis
• such low injuries are unusual in LC
 ROUX-EN-Y HEPATICOJEJUNOSTOMY

Identification of the bile ducts proximal to the stricture:

i. Dissection in area lateral to hepatic artery pulsation
• for identification of common hepatic duct
• for patients with relatively low strictures (Bismuth type 1)

ii. Expose left hepatic duct by lowering hilar plate at base of segment IV
• not disturbed area; free of adhesions
• delivers left hepatic duct & biliary confluence from undersurface of liver and makes
identification of the strictured area much easier
 Lowering of the hilar plate:
Hilar plate
Biliary confluence and left
(arrow): formed by
hepatic duct exposed by lifting
fusion of
segment IV upward after incision
connective tissue
of Glisson capsule at its base
enclosing biliary
and vascular
To display a dilated bile duct
elements with
above an iatrogenic stricture or
Glisson capsule
hilar cholangiocarcinoma
Line of incision (left) to allow extensive mobilization of segment IV.
For lifting segment IV upward
then not only opening the umbilical fissure but also incising the deepest portion of gallbladder fossa
Right, Incision of the Glisson capsule to gain access to the biliary system (arrow)
Stricture is below the confluence (Bismuth type 1)  direct anastomosis to hepatic
duct stump

Type 2 and type 3 strictures  biliary-enteric anastomosis to the left hepatic duct --
complete drainage of left and right ductal systems

Type 4 strictures 
• drainage of right lobe as well -- by dissection across the stricture and creation of a second
anastomosis to right ductal system
• Occasionally, mobilization or even partial excision of segment IV of the liver
Ligamentum teres or round ligament approach
• repair accomplished by dissection of left duct within umbilical fissure
• If difficulty to expose left hepatic duct because of
a. Adhesions or fibrosis
b. Excessive bleeding encountered
c. large, overhanging portion of liver
d. extrahepatic length of left duct (normally much greater than the right) is short
• rarely is indicated for benign strictures
• Used only if biliary confluence is intact
• high bile duct stricture (black arrow).
• At operation, the left hepatic duct was
exposed using the ligamentum teres
approach, and anastomosis was carried out
(white arrow).
 ISOLATED SECTORAL HEPATIC DUCT INJURIES

• Injuries to aberrant or “low entry” right sectoral hepatic ducts (type c)

• stricture but no bile leak (type B) –
• concomitant stricture of common hepatic duct (type E5) is present

• asymptomatic; pain; cholangitis; abnormal LFTs

• Symptomatic patients –> Biliary drainage to a Roux-en-Y loop of jejunum +/-resection of the
atrophic sector (evidence of liver atrophy(corresponding hepatic sector drained by occluded duct)

• No intervention:
• Asymptomatic patients
• injury was remote
• significant atrophy is already evident
 LIVER SPLIT AND LIVER RESECTION

To expose bile ducts for repair, it is sometimes necessary to open liver tissue as a
hepatotomy
i. Opening the umbilical fissure to obtain access to segment III duct
ii. extending the subhepatic approach to expose origin of right hepatic duct
iii. Resection of lower parts of segments IV and V to obtain exposure to the hilar plate
iv. intrahepatic hepaticojejunostomy
• resection of a portion of left lateral segments (II and III) and anastomosis to ducts exposed on cut surface of liver

• These techniques are unnecessary if approaches to left duct are possible

• Actual liver resection is rarely necessary for exposure of the bile ducts in benign post
cholecystectomy strictures
 COMBINED MODALITY APPROACHES

• complex and difficult strictures, especially in presence of intrahepatic

strictures and stones,
• even optimal surgical management -- disappointingly high incidence of
postoperative intrahepatic stone formation, cholangitis, and recurrent
stricture
• Interventional radiologic and endoscopic techniques, used as primary therapy
in this setting, are unsuccessful
• nonoperative techniques are technically impossible because of limited access
Hepaticojejunostomy with a long, defunctionalized Roux
limb, with the end secured subcutaneously or
subperitoneally
allow access for future diagnostic or therapeutic studies
• cholangioscopy, dilation, or stone removal

• blind end of Roux limb may be reaccessed by

• percutaneous puncture under fluoroscopic guidance
• small incision made under local anesthetic
for late diagnostic or therapeutic procedures long after the transjejunal tube has
been removed

• spare patient the need for repeated major surgical intervention

months or years later
 HEPATIC RESECTION

• Indications: conditions precluding biliary-enteric revision:

• prior unsuccessful repairs / refractory benign bilary stricture
• complex injury with vascular involvement, especially in patients suffering from
recurrent bouts of cholangitis or sepsis  develop sectional duct strictures or
interruptions between right-sided and left sided biliary tree

• Formal liver resection to eliminate atrophied liver or biliary duct

confluence
• surgical aim: create a more functional biliary-enteric anastomosis using
remnant liver
 LIVER TRANSPLANTATION

Indications:
• devastating combined vascular and biliary injury
• Only rarely does secondary biliary fibrosis resulting from longstanding biliary
obstruction progress to true cirrhosis

Even in experienced transplantation centers, surgical reconstruction is

preferred for most patients with benign strictures
 OPERATIVE MORBIDITY AND MORTALITY

Most common postoperative

complications
i. intraabdominal abscess,
ii. wound infection
iii. Cholangitis
iv. Sepsis
v. biliary fistula
vi. postoperative hemorrhage
vii. pneumonia
 NONOPERATIVE APPROACHES

• percutaneous balloon dilation

• biliary tree is accessed percutaneously - guidewire passed through stricture -
stricture is dilated with an angioplasty-type balloon catheter  transhepatic
stent is left in place  follow-up cholangiography and repeat dilation
• endoscopic stenting during ERCP
 References

• Blumgart Surgery of Liver, biliary tract and pancrease 6th edition

chapter 2 p 32-60 and chapter 42 p 690-712
• 2020 WSES guidelines for the detection and management of bile duct
injury during cholecystectomy
• SAGES safe cholecystectomy program
• Fischer’s Mastery of Surgery 7th edition chapter 110 p1358-1365