Bile duct injuries

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Bile duct injuries

BILE DUCT INJURIES Dr. Joe M DasJunior ResidentS3 Unit

Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to aberrant anatomy and more 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) - EgyptianRecognition 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

Observations of human gallstones were first demonstrated during autopsy by Gentile da Foligno (1341) in PaduaIn 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.

John Stough Bobbs - first elective cholecystostomy in Indianapolis for hydrops of the gallbladderIn 1878 Kocher drained an empyema of gallbladder.

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

First open cholecystectomyDr Carl Johann August Langenbuch (German surgeon) July 15, 1882, at Lazarus Krankenhaus in Berlin

Bernard Naunyn (1839-1925) - pathophysiological basis of gall stone formationHans Kehr - inventing a T tube

First laparoscopic cholecystectomy Erich Mhe in Germany in 1985

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

"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 himBILLROTH


Extra hepatic biliary tractLeft 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

Cystic duct : Length : 1 to 5 cm Diameter : 3 to 7 mmBlood supply :Distal : Gastroduodenal,retroduodenal, pancreatoduodenal arteriesProximal : Right hepatic and cystic arteries. Arteries run parallel to each other at 3 & 9 oclock position.

Common bile duct

Calots triangle(Hepatobiliary / Cystohepatic triangle)Common hepatic duct ,liver and cystic duct.Cystic artery, RHA & lymph node.

Duct of Luschka (Accessory hepatic / cholecystohepatic duct)

Variations of Accessory duct at Porta Hepatis

Anatomical variations of Gall bladderAgenesis of GB : 0.02%.


Multiple Gall Bladder1 in 3800.Should be removed even when normal.Magnetic or CT cholangiography

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

Intrahepatic & floating

Cystic duct AnomaliesOnly 33% have classical anatomic position and course.Most important : junction of cystic duct with CHDLength varies : 20% < 2cm ,majority 2-4cm.Careful dissection of the Calots triangle.

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

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

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

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.

(a) 1.4% (b) 2.6%

(c) 0.16% (d)0.08%

(e) 10.7% (f) 85%

Cystic dilatations of biliary treeTodani Classification

Ty 1- Solitary fusiform extrahepatic cyst.Ty 2 Extrahepatic supraduodenal diverticulum.Ty 3 Choledochocele - intraduodenal diverticulumTy 4a Fusiform intra & extrahepatic cysts.Ty 4b Multiple extrahepatic cysts.Ty 5 Carolis disease (multiple intrahepatic cysts)

Cystic artery variations20% cases arise from middle & left hepatic artery.Replacements : gastroduodenal ,celiac axis or independently from aorta.Abberant RHA from SMA .Double cystic artery.

Diagram shows cystic artery classification based on the relationship of the cystic artery to the Calot triangle.

Sugita R et al. Radiology 2008;248:124-1312008 by Radiological Society of North America

Diagram shows cystic artery classification based on the relationship of the cystic artery to the Calot triangle. Cystic arteries can be classified into seven subtypes on the basis of their relationship to the Calot triangle, which consists of the common hepatic duct, cystic duct (CD), and undersurface of the liver (L), and within which minute arteries frequently may be found. Types 1, 2, and 3 are associated with one cystic artery (CA), two cystic arteries, and three or more cystic arteries, respectively. Each is further subdivided as follows: Type 1a indicates one cystic artery courses at least partly through the Calot triangle. Type 1b indicates one cystic artery courses outside the Calot triangle. Type 2a indicates two cystic arteries course at least partly through the Calot triangle. Type 2b indicates one artery courses at least partly through the Calot triangle and the other artery courses outside the Calot triangle. Type 2c indicates both cystic arteries course entirely outside the Calot triangle. Type 3a indicates all arteries course through the Calot triangle. Type 3b indicates all but one artery course at least partly through the Calot triangle, while the remaining artery courses outside the Calot triangle. Type 3c (not shown) indicates two or more arteries course outside the Calot triangle. CBD = common bile duct, GB = gallbladder.

Causes of bile duct injury


Subvesical or Gallbladder bed : 25%

Major bile duct :25%

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.

Clinical features and investigationExcessive right upper quadrant pain and elevated bilirubin.

Ultrasound or CT HIDA (hepatobiliary iminodiacetic acid) ERCP : procedure of choice

Extra hepatic bile duct injuriesCommon hepatic duct most commonly injured. During dissection of Calots triangle & inadequate identification of the structures.Either partial lacerations or complete transections.

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

Cause of biliary stricturesDirect injuryClipping of ductThermal injuryIschaemiaInflammation and scarring secondary to bile leakage.

Mechanisms of injury and risk factorsAnatomic variations.

Complicated pathology.

Technical error.

Thermal and laser injuries.

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

Technical errorsCephalad 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.

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.

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


Bergmann classification of bile duct injuries

Stewart Way classification of Laparoscopic bile duct injuries

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


Amsterdam Academic Medical Center's classification (1996)

Neuhaus' classification (2000)

Csendes' classification (2001)

CUHK (Chinese University of Hong Kong), 2007

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

Most class I injuries are recognized intraoperatively (about 6070%).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

The majority of class II injuries (6070%) present withObstructive jaundice, pruritus,