Bile duct injuries

1. BILE DUCT INJURIES
Dr. Joe M Das
Junior Resident
S3 Unit

2. • Bile duct injuries represent a complex clinical
scenario seen with increased frequency
owing to
– aberrant anatomy and
– more lap cholecystectomies being performed
• Incidence :
– 0.1-0.2 % in open cholecystectomy
– 0.4-0.6 % in lap cholecystectomy

3. HISTORY

4. • Earliest known gall stones - Priestess of
Arnan (1085-945 BC) - Egyptian
• Recognition of gallstones was first
recorded by a Greek physician Alexander
Trallianus (525-605 BC)
• The first clinical description of gallstone
disease - Gordon Taylor, in his description
of the symptoms manifested by
Alexander the Great in 323 BC

5. • Observations of human gallstones were first
demonstrated during autopsy by Gentile da
Foligno (1341) in Padua
• In 1667, Michael Entmuller said, “There are no
medicine which will cure gallstones”.
• Jean Lovis Petit (1674-1750) –
– identifying the biliary colic and other signs
of this disease
– removing the gallstones after puncturing
the gall bladder with trocar and cannula in
1743.

6. • John Stough Bobbs first elective
cholecystostomy in
Indianapolis for
hydrops of the
gallbladder
• In 1878 Kocher
drained an empyema
of gallbladder.

7. • Ludwig Georg
Courvoisier (18431918).
– Law (Statistical
article on the
pathology and
surgery of the biliary
system)
– First
choledocholithotomy
– Butterflies

8. First open
cholecystectomy
•Dr Carl Johann
August
Langenbuch
(German
surgeon)
•July 15, 1882, at
Lazarus
Krankenhaus in
Berlin

9. • Bernard Naunyn
(1839-1925) pathophysiological
basis of gall stone
formation
• Hans Kehr inventing a T tube

10. First laparoscopic
cholecystectomy
• Erich Mühe in
Germany in 1985

11. • The first laparoscopic cholecystectomy in India
was done in 1990 at the J.J. Hospital, Mumbai

12. "The pleasure of a physician is little,
the gratitude of patients is rare and
even rarer is material reward, but,
these things never deter the student
who feels the call within him”
–BILLROTH

13. REVIEW ON SURGICAL
ANATOMY

15. Extra hepatic biliary tract
• Left hepatic duct – segment 2,3,4.
• Right hepatic duct
Right anterior: 5,8
Right posterior:6,7
• Hilar plate : seperates biliary confluence from
posterior aspect of caudate lobe.
• Common hepatic duct lies anterolateral to
hepatic artery and vein in the hepatoduodenal
ligament.

16. • Common bile duct :
– Length : 5 to 9cm
– Diameter : 6 to 8 mm
– Supraduodenal , retroduodenal &
intrapancreatic .
• Gall bladder :
– 7 to 10 cm length.
– 30 to 60 ml capacity.
– Fundus ,body infundibulum and neck

17. • Cystic duct :
– Length : 1 to 5 cm
– Diameter : 3 to 7 mm
• Blood supply :
– Distal : Gastroduodenal,retroduodenal,
pancreatoduodenal arteries
– Proximal : Right hepatic and cystic arteries.
Arteries run parallel to each other at
3 & 9 o’clock position.

18. Common bile duct

19. Calot’s triangle
(Hepatobiliary / Cystohepatic triangle)
• Common hepatic duct ,liver and cystic duct.
• Cystic artery, RHA & lymph node.

20. Duct of Luschka (Accessory hepatic /
cholecystohepatic duct)

21. Variations of Accessory duct at Porta
Hepatis

24. Anatomical variations of Gall bladder
• Agenesis of GB : 0.02%.
• Cholangiography

25. Multiple Gall Bladder
• 1 in 3800.
• Should be removed
even when normal.
• Magnetic or CT
cholangiography

26. Ectopic Gall Bladder
• Normally formed gall bladder in an
abnormal site.
• Intrahepatic , left sided , transverse or
retrodisplaced.
• Floating gall bladder : suspended via a
mesenteriole.

27. Intrahepatic & floating

28. Cystic duct Anomalies
• Only 33% have classical anatomic position and
course.
• Most important : junction of cystic duct with
CHD
• Length varies : 20% < 2cm ,majority 2-4cm.
• Careful dissection of the Calot’s triangle.

29. (a)Low & parallel course (15%)
(b)Adherent to CHD (6%)

30. (c)Normal course of the cystic duct(60)
(d)Short & absent cystic duct(3.5&0.5)

31. (e)Anterior spiral course to left of CHD(2)
(f)Posterior spiral course to left of CHD(13)

32. Variations of CBD & Extra hepatic
confluence.
• Convergence of hepatic ducts vary greatly.
• Sectoral ducts: nonconfluence of the ducts
with independent ending for each duct in
duodenum.
• Length of CBD varies from person to person.

33. (a) 1.4% (b) 2.6%

34. (c) 0.16% (d)0.08%

35. (e) 10.7% (f) 85%

36. Cystic dilatations of biliary tree
Todani Classification

37. • Ty 1- Solitary fusiform extrahepatic cyst.
• Ty 2 – Extrahepatic supraduodenal diverticulum.
• Ty 3 – Choledochocele - intraduodenal
diverticulum
• Ty 4a – Fusiform intra & extrahepatic cysts.
• Ty 4b – Multiple extrahepatic cysts.
• Ty 5 – Caroli’s disease (multiple intrahepatic
cysts)

38. Cystic artery variations
• 20% cases arise from middle & left hepatic
artery.
• Replacements : gastroduodenal ,celiac axis or
independently from aorta.
• Abberant RHA from SMA .
• Double cystic artery.

41. Diagram shows cystic artery classification based on the relationship of the cystic artery to
the Calot triangle.
Sugita R et al. Radiology 2008;248:124-131
©2008 by Radiological Society of North America

42. Causes of bile duct injury

44. CYSTIC DUCT INJURIES AND BILE LEAK
• Cystic duct : 50%
• Subvesical or Gallbladder bed : 25%
• Major bile duct :25%

45. • Cystic duct leak
– failure to safely ligate the cystic duct
– failed application of endoscopic clips.
• Acute cholecystitis : wide and friable
cystic duct.
• Intraoperative cholangiogram
• Endo-loop application is better.

46. Clinical features and investigation
• Excessive right upper quadrant pain and
elevated bilirubin.
• Ultrasound or CT
• HIDA (hepatobiliary iminodiacetic acid)
• ERCP : procedure of choice

47. Extra hepatic bile duct injuries
• Common hepatic duct most commonly
injured.
• During dissection of Calot’s triangle &
inadequate identification of the structures.
• Either partial lacerations or complete
transections.

48. Intrahepatic bile duct injuries
• During dissection of gallbladder off the liver
bed.
• Right hepatic duct more commonly injured
than left.
• Inadequate / incomplete cholangiogram :
convert to open.

49. Cause of biliary strictures
•
•
•
•
•
Direct injury
Clipping of duct
Thermal injury
Ischaemia
Inflammation and scarring secondary to
bile leakage.

50. Mechanisms of injury and risk factors
• Anatomic variations.
• Complicated pathology.
• Technical error.
• Thermal and laser injuries.

51. Complicated pathology
• Acute inflammation and scarring of the
triangle of calot.
• Acute cholecystitis.
• Acute pancreatitis.
• Chronic cholecystitis.
• Mirizzi syndrome
• Perforated duodenal ulcer.

52. Technical errors
• Cephalad and lateral retraction of gall bladder
is necessary to expose the structures.
• Cautious retraction in case of acute
inflammation or gangrenous gall bladder.
• Avoid application of clips too close to the
cystic duct CBD junction.

53. • Avoid strenous dissection too close to
the CBD.
• Blind application of clips to achieve
hemostasis.
• Willingness to convert to open
technique.
• Early in the surgeons learning curve.

54. Thermal and laser injuries
• Use of electrocautery
• Avoided near the CBD
• Bipolar cautery is better.
• Laser : severe injuries with tissue loss.
• Avoid usage near metallic clips
• Low intensity for short duration

56. CLASSIFICATION

57. Bergmann classification of bile duct
injuries

58. Stewart Way classification of
Laparoscopic bile duct injuries

60. A drawback of the
Bismuth
classification is that
patients with limited
strictures, isolated
right hepatic duct
strictures, or cystic
duct leaks cannot be
classified

63. Strasberg
classification is able
to classify all types
of injury and is used
extensively in
describing bile duct
injuries associated
with laparoscopic
cholecystectomy

66. • McMahon
• Amsterdam Academic Medical Center's
classification (1996)
• Neuhaus' classification (2000)
• Csendes' classification (2001)
• CUHK (Chinese University of Hong Kong), 2007

67. What are the clinical features and how
to detect these injuries?

68. • Most class I injuries are recognized
intraoperatively (about 60–70%).
• Those unrecognised present with mild
abdominal pain, abdominal distention,
ileus, with mild elevations in ALP (average
250 U/l) and bilirubin (average 2.3 mg/dl)
• Ultrasound and CT scans demonstrate an
abdominal fluid collection without dilated
bile ducts
• ERCP reveals an intact biliary tree with a
fistula

70. • The majority of class II injuries (60–70%) present
with
– Obstructive jaundice, pruritus, cholangitis, ↑
bilirubin and alkaline phosphatase levels.
• The remainder of the patients, who have
associated biliary fistulas, present similar to class
I injuries.
• Some patients may have a prolonged bile leak
from surgically placed drain that then closes,
with the subsequent development of a biliary
stricture and jaundice

71. • CT and USS –
– dilated bile ducts in patients without biliary
fistulas
– non-dilated ducts and abdominal fluid
collections in patients with associated biliary
fistulas.
• ERCP shows the lesion, invariably with
multiple clips overlying it with or without a
fistula.

73. • Patients with class III injuries present like class
I injuries, only they can have a more toxic
illness.
• About 25% of these injuries are recognized
during the index operation when bile is seen
to drain from the common (or hepatic) duct.
• The remainder of patients present later with
abdominal pain, abdominal distention, ileus,
and cholangitis

74. • Laboratory abnormalities are highly
variable
• Total bilirubin can be normal or
elevated (average of 4–5 mg/dl)
• Alkaline phosphatase can be normal
to elevated (average of 225 U/l)
• White blood cell count similarly can
be normal to mildly elevated (average
13 000/cm2)

75. • CT and ultrasound scans - an abdominal
fluid collection and nondilated bile ducts.
• ERCP distinguishes class III from other bile
duct injuries involving a biliary fistula.
• The findings in class III injuries consist of a
truncated common bile duct that is
occluded with a clip, and non-filling of the
biliary radicles .
• PTC demonstrates the proximal extent of
these injuries.

77. • Class IV injury patients present with abdominal
pain, abdominal distention, ileus, cholangitis,
hepatic abscess (20–25%)
• Unlike the other injuries, many (45%) of these
patients can have associated severe hemorrhage
requiring blood transfusions.
• CT and USS – non-dilated ducts and fluid
collections
• ERCP - injury to or occlusion of the right hepatic
duct (or a right sectoral duct) by a clip
• PTC - a fistula from the right hepatic ductal
system

78. Routine intraoperative
cholangiography
• Fletcher et al. in 1999 found that
intraoperative cholangiography had a
protective effect for complications of
cholecystectomy in a retrospective study
of 19,000 cholecystectomies.

79. Is it possible to detect these
injuries intra operatively?

80. Intraoperative clues to a bile duct injury
• Cholangiogram abnormalities:
– Failure to opacify the proximal hepatic ducts
– Narrowing of the CBD at the site of cholangiogram
catheter insertion
• Bile drainage:
– Drainage of bile from any location other than a lacerated
gallbladder
– Bile draining from a tubular structure

81. • Atypical features of cystic duct:
– A ‘cystic duct’ that is not completely
encompassed by the standard M/L. clip, which
measures 9mm in the closed position, the
structure may be the common duct
– A ‘cystic duct’ that can be traced without
interruption behind the duodenum, that will
prove to be the common duct, not the cystic
duct

82. • Anomalous anatomy:
– Second cystic duct, aberrant duct, accessory duct, or
suspected duct of Lushka, these are generally the
common duct or a hepatic duct
– Second cystic artery, this may be the right hepatic
artery
– Lymphatics surrounding the ‘cystic duct’ or more
tissue around the cystic duct than is usually
encountered, this indicates that the dissection is in
the porta
– Fibrous tissue in the gallbladder bed, indicates
transection of the proximal hepatic ducts

83. How to prevent?

84. • Proper selection of cases
• In obese patients place the optical port little
higher up from the umbilicus to avoid the
tangential view of the Calot’s triangle.
• Posterior peritoneal fold should be opened
before approaching the Calot’s triangle
anteriorly. This provides an extra mobility to
GB and helps the CHD to fall away from the CD
thereby avoiding proximal BDI during the
dissection of Calot’s triangle.
• Always dissect to the right of the line joining
the right free margin of lesser omentum to
cystic node.

85. • While dissecting the Calot’s triangle stay close
to the GB.
• It is advised that Calot’s triangle is dissected in
such a way that the retro-infundibular window
is opened first and then the window between
the cystic artery and duct is opened.
Visualisation of the double window is called
“Critical view of Strasberg”.

86. • The technique of
“critical view of
safety” of Strasberg
• Calot’s triangle is
completely unfolded
by mobilizing the
gallbladder neck
from the gallbladder
bed of the liver
before transecting
the cystic artery and
duct

88. • Always dissect to the right of the line joining the
right free margin of lesser omentum to cystic
node.
• Vessels pulsating before clipping should be
considered as hepatic artery until proved
otherwise.
• While dissecting GB from the liver bed stay close
to the GB and avoid any injury to superficial
portal radical or abnormally superficial right
anterior sectoral duct.
• Intra-operative cholangiogram may be used
routinely in order to better identify the anatomy
after dissection of Calot’s triangle.

89. • Once the Calot’s triangle is fully dissected and
cystic artery has been clipped and cut, GB is
left attached medially to only one structure,
CD.
• If the plane between the liver and GB is
absent, it might be better to leave a part of
posterior GB wall adhered to the liver bed and
cauterise its mucosa than to cause an
inadvertent injury to hepatic parenchyma
resulting in bleeds and postoperative biliary
fistula.

90. • The cystic duct and the
GB neck and
infundibulum together
looks like Lord
Ganesha’s trunk and
head (or elephant’s
trunk and head)
respectively and so also
called as Lord Ganesha’s
sign.

91. • Use the suction-irrigation cannula to aid
in dissection. The oozing surface absorbs
light with a resultant darker picture.
• In case of impacted stone in the neck, it
may be safer to transect the Hartman’s
pouch and remove the stone. The left out
mucosa can be cauterised and stump is
sutured.
• In case of a dilated CD where clip cannot
adequately close its lumen, it is advised
to use endoloop or intracorporeal
suturing for safe closure of the stump.

92. In case of excessive bleeding during the surgery:
• Have a low threshold for conversion.
• If there is continuous ooze from the
inflammed surface, liberal irrigation and
aspiration should be used.
• If there is sudden arterial spurt, compress the
area temporary with small gauge or
atraumatic grasper. Irrigate / aspirate and
clean the operative field. Effectively control
the bleeding vessel with left hand grasper,
identify the vessel and arrest bleeding with
clips or bipolar electrocautery.

93. “I would like to see the day when
somebody would be appointed
surgeon somewhere who had no
hands, for the operative part is the
least part of the work”
-Letter to Dr Henry Christian Nov 20, 1911

94. MANAGEMENT

95. HOW ESSENTIAL IS TO TREAT BILE
DUCT INJURIES?

96. • Most bile duct injuries or strictures occur as a
result of cholecystectomy for symptomatic
gallstone disease.
• The majority of these patients are young (40–
50 years), female, have a long life expectancy,
and are in the most productive years of their
life.

97. • Biliary strictures may result in significant
morbidity and mortality secondary to
complications such as biliary cirrhosis ,
cholangitis,portal hypertension.
• Because of this, it is essential that these
patients have prompt recognition of their
problem and a reliable treatment with a longterm success rate.

98. WHAT ARE THE FACTORS ONE SHOULD
CONSIDER BEFORE TREATING BILE DUCT
INJURIES?

99. 1.Timing of diagnosis -
Intra-operative
-
Early post-op
-
Late post-op
2.Extent and level of injury
3.Patient presentation
4.Hospital setup

100. WHAT ARE THE TREATMENT OPTIONS
AVAILABLE ?

101. • A multidisciplinary approach
• The team consisting of experienced
interventional radiologists, endoscopists, and
surgeons, coordinated by an experienced
hepatobiliary surgeon

102. 1) Surgical Management
2) Interventional Radiologic Techniques
3) Endoscopic Techniques
• Most of these injuries and strictures are best
repaired surgically.
SURGERY - GOLD STANDARD

103. "Surgery is the first and the highest
division of the healing art, pure in
itself, perpetual in its applicability, a
working product of heaven and sure
of fame on earth"
- Sushruta (400 B.C.)

104. PRE-OPERATIVE MANAGEMENT

105. • Early post-op period
 Sepsis /SIRS
 Treat with –Broad spectrum antibiotics
-Percutaneous biliary drainage
- Percutaneous/operative drainage
of bilomas
No hurry for surgical repair - friable tissue
-retraction of
small ducts

106. • Next step- Pre-op cholangiography (to define
anatomy)
Control bile leak with percutaneous stents
Delayed surgical repair

107. • Late post-op period
Strictures
Cholangitis
Treat with- Broad spectrum antibiotics
Urgent cholangiography
Biliary decompression
-Transhepatic biliary drainage
-Endoscopic drainage + stent
Surgical repair

108. • If patient presents only with jaundice & no
cholangitis
ERC / PTC -
to define anatomy
In these cases biliary decompression has not
been demonstrated to improve outcome
Surgical repair

109. INTRA OPERATIVE MANAGEMENT

110. • Intra-operatively, any suspicious biliary injury
1) Intra-op cholangiography
+/Careful dissection
2) Lap to open conversion is often necessary
• Isolated, small, non–cautery-based partial lateral bile
duct injury
Placement of a T tube

111. • Injury involves <50% of the circumference of
the bile duct wall
Primary closure over a T-tube

112. • More extensive biliary injury
• Significant thermal damage owing to cauterybased trauma
• Injury involving >50% of the circumference of
the bile duct wall
End-to-side choledochojejunostomy with a
Roux-en-Y loop of jejunum should be
performed

113. MANAGEMENT OF HEPATIC DUCT INJURIES

114. • Major bile duct injuries, including transections of
the common common hepatic duct, can be
repaired.
• Isolated hepatic ducts smaller than 3 mm or
those draining a single hepatic segment can be
safely ligated.
• Ducts larger than 3 mm are more likely to drain
several segments or an entire lobe and need to
be reimplanted.

115. TECHNICAL ASPECTS OF SURGICAL REPAIR

116. SURGICAL REPAIR
• The blood supply of the common duct is axial
running at 3:00 and 9:00 on the duct.
• These vessels are small and easily damaged during
extensive mobilization of the duct.
• In addition, the majority of the blood supply (60%)
comes from below, while only 38% comes from
above, further contributing to ischemia in the
proximal portion of the duct

117. • The choice and technique of repair
correlates with the success rate.
• End-to-end anastomosisThe common duct (or common hepatic
duct) has been divided and there is
sufficient length to perform an end-toend anastomosis without tension

118. Unsuccessful :
1.When repaired at the initial open
cholecystectomy
2. Class III injuries, especially laparoscopic.
• The reasons for the high failure rate of end-toend biliary anastomoses relate to ischemia
and tension.

119. Roux-en-Y hepaticojejunostomy
• Has the best success
rate for the repair of
a transection injury of
CBD/CHD

121. Certain technical factors for a successful
hepaticojejunostomy are
• Preoperative eradication of intra-abdominal
infection
• Viable ductal tissue (excise damaged ductal
tissue)
• Single-layer mucosa-to-mucosa anastomosis
• Fine, monofilament, absorbable suture
• Alleviate tension on the anastomoses

122. Stenting
• Stenting is useful, however, when very small
ducts are repaired (class IV injuries or class III
injuries where the resection has been carried
high into the porta).
• For other injuries stenting may not be
required.

123. WHEN DETECTED POST-OP….?

124. • The management of postoperative
biliary strictures following ductal
injury depends on the degree of
injury, the presence of strictureinduced complications, and the
operative risk of the patient.

125. • After recognition of a bile duct injury or
stricture, a multidisciplinary team consisting of
experienced interventional radiologists,
endoscopists, and surgeons, coordinated by an
experienced hepatobiliary surgeon, should
plan the following specific goals:
1. Control the infection (abscess or
cholangitis)
2. Drain the biloma
3. Complete the cholangiography
4. Provide definitive therapy with controlled
reconstruction or stenting

126. OVERVIEW

127. Suspected CBD injury during lap-cholecystectomy
Intra-op cholangiogram
Partial injury(<30%)
Extensive injury(>30%)
Primary repair over T-tube
Roux en Y
choledochojejunostomy
Roux en Y.
Complete transection
Injury to isolated hepatic duct
>3mm
Reimplantation or reconstruction by
Roux en Y hepaticojejunostomy
<3mm
Ligate

128. Role of Interventional Radiology

129. • Interventional
radiologic techniques
are useful in patients
with bile duct injuries,
leaks, or postoperative
strictures.

130. • These techniques allow
1)Percutaneous drainage of abdominal fluid
collections
2)Preoperative identification of the ductal
anatomy through percutaneous transhepatic
cholangiography
3)Stricture dilation with or without placement of
palliative stents for bile drainage in the patient
whose overall physiologic status precludes a
major operation.

131. • Percutaneous transhepatic biliary
dilatation:
– Intrahepatic ductal disease
– ERCP is not possible
– Adjunct to operative repair in order to assist
with identification of the proximal biliary
tree for reconstruction and for the dilation
of anastomotic strictures

132. ROLE OF ENDOSCOPIC DILATATION IN
BILIARY STRICTURES

133. • Adjunctive option in patents with a
dominant extrahepatic stricture causing
clinical symptoms.
• Requires multiple sessions of dilations
• Nonischemic strictures (anastomotic
strictures) respond best.

134. • Metalic stents are more durable than
plastic stents
• Endoscopic dilation also has a low
mortality rate, but it has a significant
morbidity rate.

135. • Complications following endoscopic
biliary interventions:
– Hemobilia
– Bile leak
– Pancreatitis
– Cholangitis
– Re-stricture

136. POST-REPAIR COMPLICATIONS

137. 1.
2.
3.
4.
5.
6.
7.
8.
Cholangitis
Pancreatitis
Stent occlusion
Stent migration
Ductal perforation
Restricturing
Biliary fistula
Hemobilia

138. MANAGEMENT OF BILIARY FISTULA

139. • To define biliary fistula –
‘ a bilirubin rich drainage lasting for more
than 5 days’
• Most of them resolve spontaneously with
conservative management.
• 3 R’S

140. 3 Rs
• Resuscitation
• Restitution
• Rehabilitation

141. Resuscitation
 The first stage in the management is the
restoration of volume using crystalloid and
colloid products as appropriate to restore
oxygen carrying capacity and plasma oncotic
pressure.
 Blood PCV 30%
 Albumin -3

142. • Control of sepsis
• Per cutaneous drainage
• Antibiotcs should only be given for defined
infections and for a set duration of therapy
• Nutritional support
• Cholangiography

143. Non-operative management
• Usually for low output fistula
• Percutaneous drainage
• Trans-hepatic stenting

144. Surgical intervention
• For early high output fistula
• Persistent sepsis
Reoperation

145. References
•
•
•
•
Surg Clin N Am 90 (2010) 787-802
Surg Clin N Am 88 (2008) 1329-1343
Schwartz's Principles of Surgery, 9e
Sabiston Textbook of Surgery, 17e

149. THANK YOU