Bile Duct Injuries (BDIs)

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CASE PRESENTATION BY : DR MUHAMMAD UMAR NISARPGT (SURGERY)

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PATIENT: XYZAGE: 50YRSGENDER: FEMALE RESIDENCE: sarghodaD.O.A: 27-07-2015

9/6/20153PATIENT PROFILE :

known diabetic 16 years

Off and on Pain in RHC 03 yearsOff and on nausea/ vomiting - 03 years

9/6/20154Presenting complaints:

PAST HX: C section 1 year back

SYSTEMIC HX: FAMILY HX: NADPERSONAL HX:

50 years Old lady lying comfortabely in bed well oriented in time place and person. B.P : 130/80 mmHgPulse : 82/minTemp : Afebrile R.R : 19/minExamination

Pallor : absentCyanosis : absent Jaundice : absent Thyroid : not enlarge Edema : absentLymph node : not palpable

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Chest: CNS CVS

Abdomen:Soft Non tender No visceromegalyBS presentExamination NAD

LabsBlood CP : Hb = 11.6 mg/dl , WBC,s = 6.21 X 109/l Platelets = 177x 109 /l

RFTs = WNLLFTs = WNLBSR= 16.1mmol/l

Urine RE= Normal

9/6/20159

Ultrasound Abdomen Chest XRAY

Cholelithiasis

Normal study

Open cholecystectomy was done on 29-07-2015Abdomen was opened via right upper transverse incisionPer op findings were thick walled gall bladder and omental adhesionsCystic artery ligatedCystic duct tiedGall bladder was removedHomeostasis secured, abdomen closedSurgery

Patient was stable vitally Abdomen was soft and there was tenderness at wound sitePatient was discharged 2 days after surgery

Post op

Patient presented again in emergency on 5th Aug 2015 with C/O Pain RHC Abdominal distentionNausea and anorexia Yellowish discoloration of scleraClay colored stool and dark color urineGPE:Anemia : presentJaundice : present

AbdomenRt upper transverse scar of cholecystectomyDistended TenderGuarding BS +ve

Blood CP : Hb = 8.6 g/dl , WBC,s = 16.21 X 109/l Platelets = 442x 109 /l

RFTs = Urea: 18.4mmol/lCreat: 314 mmol/lLFTs = Bili: 55 umol/lBSR= 252 mg/dl

Coagulation profile: WNLSerum Amylase: WNL

labs

Abdomen was opened via previous scar. Suction of almost 2L of bile was done.Per op findings were transected CBD at cystic duct level with proximal stump of about 3-4cm from confluence and distal stump was approx 2-3 cm.Peritoneal cavity washed with 8L of fluid.CBD stent placed inside the CBD and end to end anastomosis done with vicryl 6/0.Drains placed in RHC and in Pelvis.Abdomen closed ASD done

Re-exploration

Kept in ICU for 2 days and in ward for 8 days with daily output in RHC drain of 500-800mlThus the patient is considered to be managed on the lines of controlled biliary fistulaDischarged on 12th POD with RHC drain in placeAdvised follow up after 2 weeksFirst post op visit:Daily output in drain= 400-600mlAbd: soft, non tenderLFTs: bili- 26 umol/lCoag : WNL

Post op

IATROGENIC BILE DUCT INJURIES

Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to aberrant anatomymore lap cholecystectomies being performedIncidence : 0.1-0.2 % in open cholecystectomy0.4-0.6 % in lap cholecystectomy

HISTORY

Earliest known gall stones - Priestess of Arnan (1085-945 BC) Egyptian

The first clinical description of gallstone disease - Gordon Taylor, in his description of the symptoms manifested by Alexander the Great in 323 BC

John Stough Bobbs - first elective cholecystostomy in Indianapolis for hydrops of the gallbladder

In 1878 Kocher drained an empyema of gallbladder.

Ludwig George Courvoisier (1843-1918).Law (Statistical article on the pathology and surgery of the biliary system) First choledocholithotomy

First open cholecystectomyDr Carl Johann August Langenbuch (German surgeon)

July 15, 1882, at Lazarus Krankenhaus in Berlin

Hans Kehr invented a T tube

First laparoscopic cholecystectomy Erich Mhe in Germany in 1985

REVIEW ON SURGICAL ANATOMY

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

Common bile duct : Length : 5 to 9cmDiameter : 6 to 8 mmSupraduodenal , retroduodenal & intrapancreatic .Gall bladder : 7 to 10 cm length.30 to 60 ml capacity.Fundus ,body infundibulum and neck

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The cranial segments : cystic artery and the hepatic arteries, especially the right (R) hepatic artery.

The caudal segment:pancreaticoduodenal artery through the retroduodenal artery.

The middle segment :is vascularized by an axial network of a varying number of arterial anastomoses between the cranial and caudal supplies.

Blood supply of CBD

60% by the distal vessels

38% by the cranial ones

2% by a nonaxial supply from common hepatic artery

This arterial pattern predisposes the supraduodenal segment of the common bile duct to ischemic damage and resulting in strictures.CBD blood supply

space bordered by:

Cystic duct inferiorly, Common hepatic artery medially

Superior border of the cystic artery

Calots triangle(Cystohepatic triangle)

Variations in cystic duct

Iatrogenic injury Cholecystectomy Gastrectomy Pancreatectomy ERCP

TraumaBile Duct Injuries (BDI)

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Inflammation in the porta,Variable biliary anatomy,Inappropriate exposure,Aggressive attempts at hemostasis,Surgeon inexperience. 97% due to visual misperception, only 3% accounts for technical skills and knowledge.Risk factors

Misperception .. With sufficient cephalad retraction of the gall bladder fundus ,the cystic duct overlies the common hepatc duct running in a parrellel path. without inferolateral traction of the gallbladder infundibulum to dossociate this structures, the dissection of apparent cystic duct may actually include CBD

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

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.Technical errors

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.

Use of electrocautery

Avoided near the CBD

Bipolar cautery is better.

Avoid usage near metallic clips

Low intensity for short duration

Thermal and laser injuries

CLASSIFICATION

Era of Open Chole

Based upon level of biliary strictures with respect to hepatic bifurcation

Type 1-5.

Helps surgeon choose appropriate site for repairBismuth classification (1982)

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

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

BL from minor duct Cystic duct leak Liver bed leakAccessory duct leak

Communication between liver and duodenum via major ducts unaffectedType A

Occlusion of the part of biliary tree

Usually due to Rt abberant duct ligature

May be segmental,sectorial, main RHD Type B

Transection of aberrant right hepatic ducts

Similar to B but

Presents and treated differently from BType C

Lateral injury to main extrahepatic bile ducts Similar to ABile collectionDissimilar to ALocation on the main biliary treeConsequences more severe RHD, CHD, CBD may be involvedType D

E: injury to main duct (Bismuth)E1: Transection >2cm from confluenceE2: Transection