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Pongsatorn Tangtawee, MD
HPB division, Department of Surgery
Ramathibodi Hospital
Prevention
Introduction
The first planned cholecystectomy in the world was
Couvoissier in 1890.
The first iatrogenic bile duct injury was described by
Introduction
Biliary injury is the most common severe
complication of cholecystectomy.
incidence of bile duct injuries has risen from 0.1%-
Introduction
pouch,
short cystic duct, and Mirizzis syndrome
abnormal biliary anatomy
Norman Oneil Machado, Diagnostic and Therapeutic Endoscopy Volume 2011
than 120minutes
more than half of all such injuries
leaks or stricture
Bile leaks subhepatic bile collection
Classification
Classification
Investigation
Intraoperative
IOC
ERCP
Investigation
MRCP is a sensitive (85%-100%) and
preoperative diagnosis
MRC
P
PTC
Management
Initial Management
Concept of initial management
Control of sepsis peritoneal and biliary
Intraoperative management
Only 15% to 30% of biliary injuries are
Intraoperative management
Postoperative BDI
management
Early or Elective should be consider
Controversial in HPB surgeon
Postoperative BDI
management
3 out of 4 failures in 25 HJs occurred in
patients who had undergone early
reconstruction (within 6 weeks of
cholecystectomy)
Boerma D, Ann Surg 2001;234:7507.
We do not recommend early repair and
have performed early (within 4 weeks)
repair in only 11 out of 362 patients in
whom we have performed HJ for BDI
between 1989 and 2005
Strasberg A injury
injuries maintain continuity with the rest of the bile
ducts
Easily treated through endoscopic intervention to
Strasberg B injury
Segmentary bile duct occlusion
If mild pain and elevation of LFT are present
prognosis is poor
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348
Strasberg C injury
accessory right duct is sectioned but the
other intervention
If this does not happen, therapeutic options
Strasberg D injury
Partial injury of the common bile duct in
Strasberg D injury
In the setting of a devascularized duct
Strasberg E injury
Complete loss of common and/or hepatic
tissue
More complex and hard to surgical
treatment
Mercado MA et al, World J Gastrointest Surg 2011 April 27; 3(4): 4348
Consideration
Injuries that involve the hepatic duct
injury.
Biliary injuries associated with portal
Key of successfully
Exposure of damaged area avoiding too much
dissection
The end of injured bile duct has to be free from burns
and attritions
Intraoperative cholangiography in every bile leakage
Vascular integrity should be confirmed
Hepaticojejunostomy with an isolated Roux-en-Y
Opposition of both mucosas with reabsorbable suture
Use of magnification
Vasculobiliary injury
Vasculobiliary injury
vasculobiliary injury
Rouvieres sulcus
Necessary
Surgical technique
Hepp-Couinaud
Soupault
-Couinaud
WEDGE SEGMENT
III
LONGMIRE PROCEDURE
Summary
BDI poor prognosis
Multiple risk factor Most important
vasculobiliary injury
Investigation : immediately IOC Do
not assume
Late MRCP is Gold standard
Summary
Concept treatment
Control of sepsis peritoneal and
follow by type
Thank You