Bile Duct Injuries (BDIs)
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CASE PRESENTATION BY : DR MUHAMMAD UMAR NISARPGT (SURGERY)
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
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
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
Ultrasound Abdomen Chest XRAY
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
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
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
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
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
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
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)
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
Era of Open Chole
Based upon level of biliary strictures with respect to hepatic bifurcation
Helps surgeon choose appropriate site for repairBismuth classification (1982)
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