IATROGENIC BILE DUCT INJURIES

DR RAJNEESH VARSHNEY
MS, DNB

SURGICAL GASTROENTEROLOGIST

SRMSIMS, BAREILLY

Widespread acceptance in early 1990s Gold Standard treatment for gallbladder removal General advantages of LCMIS approach
Reduced hospitalization Improved recovery time Decreased PO pain Improved cosmesis Reduced cost

LC has been associated with a higher incidence of IA bile duct injuries

LC0.4 to 0.8% Traditional OC0.1-0.3%

Association:

Increased mortality and morbidity Reduced long-term survival Reduced quality of life

Infrequentbut among the leading sources of malpractice claims against surgeons. Between 34% and 49% of surgeons are expected to cause such an injury during their career. Awareness and preventative methods are of clinical importance to surgeons.

Risk Factors
Anatomical Anatomical variations (biliary and vasculature) Bleeding, scarring, obesity Laparoscopic Lack of Depth Perception, Tactile Feedback, Full Manual Maneuverability Improper surgical approach
Improper Lateral retraction (insufficient or excessive) 0 degree scope Approach plane too deep

Lack of conversion to OC during difficult cases

Anatomical Misidentification: excision, incision, or transection of biliary anatomy Injuries: common bile duct, common hepatic duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments Anatomical variations (biliary and vasculature)

Electrocautery, thermal injury: stricture of CBD or hepatic ducts, bile leak Mechanical trauma: stricture of the biliary ducts, bile leaks

--Mistaking the common bile duct for the cystic duct

PATTERNS OF BILIARY TRACT INJURIES

 Inappropriate use of electrocautery near biliary ducts May lead to stricture and/or bile leaks Mechanical trauma can have similar effects

Lahey Clinic, Burlington, MA.1994

 Type A Cystic duct leaks or leaks from small ducts in the liver bed Type B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts Type C Transection without ligation of the aberrant right hepatic ducts Type D Lateral injuries to major bile ducts Type E Subdivided as per Bismuth classification into E1 to E5

E: injury to main duct (Bismuth)

E1: Transection >2cm from confluence E2: Transection <2cm from confluence E3: Transection in hilum E4: Seperation of major ducts in hilum E5: Type C plus injury in hilum

Type 1 Leaks from cystic duct stump or small ducts in liver bed Type 2 Partial CBD/CHD wall injuries without (2A) or with (2B) tissue loss Type 3 CBD/CHD transection without (3A) or with (3B) tissue loss Type 4 Right/Left hepatic duct or sectoral duct injuries without (4A) or with (4B) tissue loss Type 5 Bile duct injuries associated with vascular injuries

1 Insecure closure of cystic duct; too deep dissection into gallbladder bed 2 Incision of CBD instead of cystic duct for operative Cholangiogram; Clipping of CBD but recognized; Laceration of cystic duct/CBD junction; Diathermy injury to CBD/CHD 3 CBD mistaken as cystic duct, with CBD/CHD transected or Resected; Diathermy injury 4 Right HD or sectoral duct mistaken for cystic duct 5 Right hepatic artery mistaken for cystic artery; Diathermy or clip injuries to right hepatic artery

 Only 25-33% of injures are recognized intraoperatively If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury) If not experienced, perform the cholangiogram laparoscopically with intent of referring patient (placement of drains) Consult an experienced hepatobiliary surgeon

Quicker the repair, the better the outcome!!! Acute Management

Biliary catheter for decompression of biliary tract and control of bile leaks Percutaneous drainage of intraperitoneal bile collection

DRAIN

REFRAIN

TRAIN

Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of the bile duct injury. Broad-spectrum antibiotics No need for an urgent laparotomy. Biliary reconstruction in the presence of peritonitis results a statistically worse outcome in patients. No need for urgent with reconstruction of the biliary tree. The inflammation, scar formation and development of fibrosis take several weeks to subside. Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.

Patient presents with

Vague abdominal pain, nausea, fever, jaundice, vomiting

Investigation
Ultrasonagraphy and CT (ductal dilatation and intra-abdominal collection) Cholangiogram
ERCPbiliary anatomy and assess the injury PTCdefine biliary anatomy proximal to injury MRCPnoninvasive (can miss minor leaks)

MR angiographyvascular injuries

MANAGEMENT OF BILE DUCT INJURY

Preoperative imaging
Is there subhepatic abscess or collection? Is there ongoing bile leakage ? What is the level of biliary injury ? Are there associated vascular injuries / Is there evidence of lobar atrophy ?

Corrective Treatment
Endoscopic stenting for strictures T-tube placement for minor lacerations

Primary duct-to-duct repair only if tension free anastomosis available Biliary anastomosis with jejunal loop for major excisional injuries

Attention to operative details (insufficient close or deep plane) Stasbergs critical view of safety Appropriate Handling of Gallbladder Careful use of diathermy Recognition of Biliary and Vasculature Anomalies

LW Way, et al