Biliary Injuries During

Laparoscopic Cholecystectomy

Dr.Atul kumar Mishra M.S (Gen.Surgery)

Historical perspective First planned cholecystectomy in the

world was performed by Carl Langenbuch in 1882.

First choledochotomy was performed by Couvoisser in 1890.

First iatrogenic bile duct injury was described by Sprengel in 1891.

Prof. Dr. Med Erich Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy in 1985.

Biliary Anatomy

a. Right hepatic duct.b. Left hepatic duct.c. Common hepatic duct.d. Portal vein.e. Hepatic artery.f. Gastroduodenal artery.g. Right gastroepiploic artery.h. Common bile duct.i. Fundus of the gallbladder.j. Body of the gallbladder.k. Infundibulum.l. Cystic duct.m. Cystic artery.n. Superior pancreaticoduodenal artery.

Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy

Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said that anomalies are rule, not

the exception. ( Maingot’s abdominal operations)

Anatomy

Calot's triangle bounded by cystic duct,

cystic artery, and common hepatic duct.

Hepatocystic triangle bounded by gallbladder wall and cystic duct, liver edge, and common hepatic duct; the cystic artery (and hence Calot's triangle) lies within this space.

(Maingot’s abdominal operation)

Aim of the laparoscopic cholecystectomy

Surgery (TODAY)->Discharge on same/next day

Complicated / InjuryLong hospital stayRepeated investigations like USG and ERCPRadiologic interventionsRe-operations

Laparoscopic cholecystectomy Pros and cons

General advantages Shorter stay in hospital Faster recovery period Reduced post-op recovery time Less postoperative pain Improved cosmetic outcome

Disadvantage Increase in serious bile duct

complications and injuries

• Reverse Trendelenburg (30 degrees) with left arm out at 90 degrees relative to the body’s axis

• Titled left 15 degrees after optical trocar placement

Operating Room Setup

Trocar PlacementEpigastric region, below XP

Mid-A, between 12th rib and iliac crest

Subcostal, Mid-Clavicular Umbilical

region

Introduction Open cholecystectomy was standard practice for

treatment of symptomatic gall bladder disease until late 1980’s.

At present 90% of cholecystectomies performed by LC which is one of the commonest surgical procedure in world.

Unfortunately, widespread application of LC led to concurrent rise in incidence of major bile duct injuries (BDI),which are more complicated than after open procedures.

Since its introduction and routine use in 1990s, the incidence of biliary injuries has doubled from 0.2% to 0.4% and remained constant despite advances in knowledge, technique, and technology.

Mistaking common bile duct for the cystic duct

Classic Laparoscopic Injury

Inappropriate use of electrocautery near biliary ducts

May lead to stricture and/or bile leaks

Mechanical trauma can have similar effects

Thermal Injuries

Lahey Clinic, Burlington, MA.1994

Bile duct injuries during cholecystectomy

In 1990s, high rate of biliary injury was due to learning curve effect.

Surgeon had 1.7% chance of a bile duct injury occuring in first case and 0.17% at the 50th case.

However most surgeons passed through learning curve, steady – state reached, but there has been no significant improvement in the incidence of biliary duct injuries.

Biliary Injuries during Cholecystectomy

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative Biliary tract injuries.

On other hand LC has been associated with 2.5-fold to 4-fold increase in the incidence of postoperative BDI compared with OC.

These preventable injuries can be devastating, increasing morbidity, mortality, and medical cost, while decreasing the patient’s quality of life.

Biliary injuries will always exist, and we need to be aware of the best methods to avoid, evaluate, and treat them.

Incidence of IBDI following cholecystectomy (%)

Author IBDI incidence following OC

IBDI Incidence following LC

Mc Mohan et al,1995 0.2 0.81

Strassberg et al, 1995 0.07 0.5

Shea et al,1996 0.19-0.29 0.36-0.47

Targarona et al, 1998 0.6 0.95

Lillemoe et al, 2000 0.3 0.4-0.6

Gazzaniga et al, 2001 0.0-0.5 0.07-0.95

Savar et al,2004 0.18 0.21

Moore et al,2004 0.2 0.4

Misra et al,2004 0.1-0.3 0.4-0.6

Gentileschi et al,2004 0.0-0.7 0.1-1.1

Kaman et al,2006 0.3 0.6

Risk Factors for Biliary tract injury

Surgeon related factors Lack of experience (learning curve) Misidentification of biliary anatomy Intraoperative bleeding Lack of recognition of anatomical

variations of biliary tree Improper interpretation of IOC Improperly functioning equipment

Risk for biliary tract injury

Patient related Acute and chronic cholecystitis Empyema Long standing recurrent disease ->

fibrosis Porcelain gallbladder Obesity Previous surgery Male sex Advanced age

The Effect of Acute Cholecystitis on Lap. cholecystectomy

complications Complication rate three times

greater than for elective LC. Early cholecystectomy (72 h)

outcome better than delayed cholecystectomy.

Conversion rate to open cholecystectomy is higher than elective cholecystectomy 35% vs 9%.

Risk Factors for biliary tract injuries Anatomic Variations

Present in 18 – 39% cases Dangerous variations predisposing to BTI are present in only 3-6% of cases

Abnormal biliary anatomy

Short cystic duct, cystic duct entering in the right duct- Accessory right hepatic duct

Arterial anomalies Right hepatic artery

running parallel to the cystic duct

Anomalous or accessory right hepatic artery

(Sabiston text book of surgery 19thedtn.)

Summary of Causes of Bile Duct Injuries

Misidentification of Common bile duct Common hepatic duct An aberrant duct (usually on the right side)

Technical failure such as Slippage of clips placed on the cystic duct Inadvertent thermal injury to CBD Tenting of CBD during clip placement Disruption of a bile duct entering directly into gallbladder fossa .

(Goal of dissection should be conclusive identification of cystic structure within Calot triangle)

(If the cystic duct and cystic artery are conclusively and correctly identified before dividing, more than 70% of bile duct injuries would be avoided )

Technique Four methods of identification of cystic

structures during cholecystectomy

1) Routine cholangiography2) Critical view technique3) Infundibular technique-> widely used4) Dissection of main bile duct with visualization

of cystic duct or common duct insertion->

( increased chance of either thermal or retraction injury to CBD, aberrant insertion

of cystic duct can also complicate this approach)

Routine intra-op cholangiogram (IOC)Laparoscopic ultrasonography

Performed routinely or not ?

Done via presumed cystic duct

If this happens to be CBD, injury has already occurred!!

IOC does not identify all aberrant ducts

Arterial anatomy not identified

IOC does not prevent BDI but may reduce its severity ( if correctly performed & interpreted, IOC can prevent complete CBD transection)

IOC higher rate of intra-op identification of BDI decreased cost of treatment & shorter hospital stay

If critical view not obtained due to inflamation or hostile anatomy perform IOC prior to dividing cystic duct .Routine IOC reduces CBD injuries from 0.58% to 0.39% (American Medicare data base study)

Critical view of safety

Calot’s triangle dissected free of all tissue except cystic duct & artery

Base of liver bed exposed When this view is

achieved, the two structures entering GB can only be cystic duct & artery

Not necessary to see CBD

Infundibular technique, although widely used, is prone to failure in situations where cystic duct is hidden because of diffuculty retracting the gallbladder as a result of severe inflammation or one or more large stone effacing or fusing the cystic duct-common duct junction.

In such situation, area where infundibulum narrows can be interpreted to be cystic duct when it is actually the cystic duct and common duct together.

(A)Usual anatomy when infundibular technique applied. Cyst duct-gallbladder junction is characterized by a flaring tunnel shape(boldlines). Arrow represents circumferential dissection of CD-gallbladder junction during infundibular technique.

(B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries.

CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg 2008;15(3):285;)

Cystic duct or CBD?2 – 3mm wide 5mm wide CD > 5mm – Is it CBD?

Even with low cystic duct insertion, CD rarely goes behind duodenum

CBD goes behind duodenum

Duct behind duodenum must be CBD

Double cystic duct very rare

-- 2 ducts seem to go towards inflammed Gallbladder – one must be CBD

No vessels on surface

Vessels on surface

--

Classical LC BDI

Type A Cystic duct leaks or leaks from small ducts in liver bed

Type B Occlusion of aberrant right hepatic ducts

Type C Transection of aberrant right hepatic ducts

Type D Partial (<50%) transection of major bile duct

Type E Transection involve >50%

Subdivided as per Bismuth classification into E1 to E5

Strasburg Classification

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

Strasburg Classification, cont’d

Class I CBD mistaken for cystic duct, but error recognized before CBD is divided.Class II Damage to CHD from clips or cautery placed on duct. Often occurs where visibility is limited due to inflammation or bleeding.Class III Most common (60%), CBD mistaken for cystic duct. Common duct is transected and variable portion that includes junction of cystic and common duct is excised .Class IV Damage to right hepatic duct , either because this structure is mistaken for cystic duct, or injured during dissection.

Bile duct injury

Prevention should be main point (much more important than treatment)

ALL laparoscopic cholecystectomies ARE difficult! None of them is easy!

If injury occurred, …who should treat it?when should it be treated?how should it be treated?

Prevention 30° laparoscope, high quality imaging equipment Firm cephalic traction on fundus & lateral

traction on infundibulum, so cystic duct perpendicular to CBD

Dissect infundibulo-cystic junction Expose “Critical view of safety” before dividing

cystic duct Convert to open, if unable to mobilise

infundibulum or bleeding or inflammation in Calot’s triangle

Routine intra-op cholangiogram Intraoperative laparoscopic ultrasound (IOUS) .

Mastery of Surgery 6th ed.

Changing the Culture of Cholecystectomy: Stopping Rules

Safety and avoiding BDI should be paramount concern to surgeon performing LC.

LC can be converted to open procedure or even aborted if local conditions present unacceptable risks of danger.

As Strasberg points out, the negative effects of conversion or even aborting procedure and placing a cholecystostomy tube are minor compared with the negative effect of a BDI.

Failure of progression of dissection, inability to grasp and retract gallbladder, anatomic ambiguity, poor visualization of field due to hemorrhage, should trigger the surgeon to consider alternate approach.

Conversion rate < 5% can be expected in hands of a well trained laparoscopic surgeon.

Timing of Identification

• Intra-op

• Unexpected ductal structures seen• Bile leak into field from lacerated or

transected duct

• Post-op

• Depends on continuity of bile duct & • Presence or absence of bile leak

Presentation of Bile Duct Injuries

About 25% recognized intraoperatively. About 25% discovered within 24 hours post- operative About 50% present weeks to years post-operative. Most BDI are not recognized intraoperatively, and patients sent

home after or within 24 hours. Patients who fails to recover within first few days or develop

progressive vague abdominal symptoms. Abdominal fullness, distension, nausea, vomiting, abdominal pain,

fever and chills. Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis,

or multi organ system failure. Clinical presentation- Biliary obstructions-> anorexia, jaundice, liver enzyme

elevation Bile leaks Both can occur simultaneously Concomitant vascular injuries (complicate matter) Obstruction secondary to biliary stricture appear weeks to month

later and may present with recurrent colangitis, obstructive jaundice, or secondary biliary cirrosis.

If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury)

If not experienced, perform cholangiogram laparoscopically with intent of referring patient (placement of drains)

Consult an experienced hepatobiliary surgeon

Quicker the repair, better the outcome!!!

Acute Management Biliary catheter for decompression of biliary

tract and control of bile leaks Percutaneous drainage of intraperitoneal bile

collection

Intraoperative Detection

Clinical Presentation (post-op)

• Obstruction• Clip ligation or resection of CBD

obstructive jaundice, cholangitis

• Bile Leak• Bile from intra-op drain or• More commonly, localized biloma or

free bile ascites / peritonitis, if no drain• Diffuse abdominal pain & persistent

ileus several days post-op high index of suspicion possible unrecognized BDI

Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of bile duct injury.

Broad-spectrum antibiotics No need for an urgent laparotomy. Biliary

reconstruction in presence of peritonitis results a statistically worse outcome.

No need for urgent with reconstruction of biliary tree. Inflammation, scar formation and development of fibrosis take several weeks to subside.

Reconstruction of biliary tract is best performed electively after interval of at least 6 to 8 weeks.

Post-Operative Detection Plan

Investigation Ultrasonagraphy and CT -- Ductal dilatation

intra-abdominal collection and dilatation of biliary tree.

Cholangiogram ERCP—biliary anatomy and assess the

injury PTC—define biliary anatomy proximal to

injury MRCP—noninvasive (can miss minor

leaks)

HIDA scan -- If doubt exists, HIDA scan can confirm leak but not the specific leak site

MR angiography—vascular injuries

BDI Management

When realise that there is an injury, ASK for HELP!

If possible do not try to repair, even you are experienced

An experienced and FRESH surgeon should repair the injury.

If it is impossible AND it is a difficult injury that you can not treat, place catheters and refer the patient.There is no ‘Tissue Lost’, primary repair (end to end CBD repair) over T-tube???

stricture rate is high!!!

There is ‘Tissue Lost’, biliodigestive anastomosis:

choledocoduodenostomy/ Roux-en-Y hepaticojejunostomy Primary repair high incidence of failure percutaneous or endoscopic balloon dilatation later

Preoperative Investigation and Preparation for the Procedure

■ Communication with previous surgeon■ Previous surgical report■ Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST, albumin, coagulation parameters, white blood cell count

Principles of Repair ■ Anastomosis should be tension free, with good

blood supply, mucosa to mucosa and of adequate caliber.■ Hepaticojejunostomy should be used in preference to either choledochocholedocotomy or choledochoduodenostomy.■ Anterior longitudinal opening in the bile duct with a long side-to-side anastomosis is preferred.■ Dissection behind the ducts should be minimized in order to minimize devascularization of the duct.

Timing of RepairFactors favoring immediate repair are: (1) Early referral (2) Lack of right upper quadrant bile collection (3) Simple injuries (4) No vascular injury and (5) Stable patient Factors favoring delayed repair are: (1) Late (less than 1week after injury) referral (2) Complex injuries (types E4, E5) (3) Thermal etiology (4) Concomitant ischemic injury

Strasburg classification

Type A

No reconstructionTreated endoscopicaly

Type B & CPotentialy serious injuriesMore common since introduction of LC

Type B

Silent

Asymptomatic atrophy of involved liverCompensated by hypertrophy of normally drained liver

Pain or cholangitis many yrs. after injury

Type C

Biliary fistula

Volume less

Converted to silent Type B

Persistence

Reconstruction

Type D

<25%

25% - 50% or Caused by diathermy orSmall bile duct

Type E (>50%)

Repaired primarily Over T-tube

Reconstruction by hepaticojejunostomy

B,C and E1 to E5 are major biliary injuries

ERCP – multiple stents

• Lateral duct wall injury or cystic duct leak transampullary stent controls leak & provides definitive treatment

• Distal CBD must be intact to augment internal

drainage with endoscopic stent

Simpler injuries types A and D may be treated in

community

setting when discovered intraoperatively by endoscopic or

percutaneous techniques when they present in postoperative

period.

More complex injuries that require hepaticojejunostomy

for repair (types B and C injuries and most to type E

injuries).

More complex injuries types E1 and E2 may also be treated

by nonsurgical techniques when they present as

strictures.

Notations >2 cm and <2 cm in types E1 and E2 indicate

length of common hepatic duct remaining.

Bile leak

Immediate intra operative diagnosis

Delayed diagnosis

injurMinor y Major injury

Repair over T-tube

No experienced hepato-Biliary surgeon Clip open ductDrainIV antibioticsTransfer to tertiary centre

Experienced hepatobiliary surgeon available

Call second surgeonRoux-en-Y hepatico-jejunostomy

Drainage

Low -output High-output

Observe

Resolve < 5-7 daysContinued ERCP

Duct of Luschka

Cystic duct stump leak

Suspected CBD injury

SphinctrectomyStent± sphincterectomy

PTC to deliniate anatomyControl drainageRepair by experienced hepatobiliary surgeon

Cholangiography (ERCP + PTC)

Percutaneous transhepatic cholangiography (PTC)

Defines proximal anatomy

Allows placement of percutaneous transhepatic biliary catheters to decompress biliary tree treats or prevents cholangitis & controls bile leak

ERCP – clips across CBD

CBD transection normal-sized distal CBD upto site of transection

Percutaneous transhepatic cholangiography (PTC) necessary

Surgery

Intraoperative repair

Surgical repairCholedocho-choledochostomy

Surgical repair Choledocho-duodenostomy

Biliary enteric anastomosis Most laparoscopic

BDI – complete discontinuity of biliary tree

Surgical reconstruction, Roux-en-Y hepaticojejunostomy

Tension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct

Surgical repair Hepatico-jejunostomy (Roux-en-Y)

Definitive management Goal

Reestablishment of bile flow into proximal GIT

In a manner that prevents cholangitis, sludge or stone formation, restricturing & progressive liver injury

Bile duct intact & simply narrowed percutaneous or endoscopic dilatation

Treatment summary Strasberg Type A – ERCP +

sphincterotomy + stent

Type B & C – Traditional surgical hepaticojejunostomy

Type D – Primary repair over an adjacently placed T-tube (if no evidence of significant ischemia or cautery damage at site of injury)

More extensive type D & E injuries –

Roux an-Y hepaticojejunostomy over a 5-F pediatric feeding tube to serve as a biliary stent

Summary

• Multidisciplinary management of BDI expertise of surgeons, radiologists & gastroenterologists

• Mismanagement lifelong disability & chronic liver disease

• BDI with lap. Chole results of operative repair, excellent in Specialist Centres