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, 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

CT and USS dilated bile ducts in patients without biliary fistulasnon-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.

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

Laboratory abnormalities are highly variable Total bilirubin can be normal or elevated (average of 45 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)

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.

Class IV injury patients present with abdominal pain, abdominal distention, ileus, cholangitis, hepatic abscess (2025%) 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

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

Is it possible to detect these injuries intra operatively?

Intraoperative clues to a bile duct injuryCholangiogram abnormalities:Failure to opacify the proximal hepatic ductsNarrowing of the CBD at the site of cholangiogram catheter insertionBile drainage:Drainage of bile from any location other than a lacerated gallbladderBile draining from a tubular structure

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 ductA cystic duct that can be traced without interruption behind the duodenum, that will prove to be the common duct, not the cystic duct

Anomalous anatomy:Second cystic duct, aberrant duct, accessory duct, or suspected duct of Lushka, these are generally the common duct or a hepatic ductSecond cystic artery, this may be the right hepatic arteryLymphatics surrounding the cystic duct or more tissue around the cystic duct than is usually encountered, this indicates that the dissection is in the portaFibrous tissue in the gallbladder bed, indicates transection of the proximal hepatic ducts

How to prevent?

Proper selection of casesIn obese patients place the optical port little higher up from the umbilicus to avoid the tangential view of the Calots triangle.Posterior peritoneal fold should be opened before approaching the Calots 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 Calots triangle.Always dissect to the right of the line joining the right free margin of lesser omentum to cystic node.

While dissecting the Calots triangle stay close to the GB. It is advised that Calots 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.

The technique of critical view of safety of StrasbergCalots triangle is completely unfolded by mobilizing the gallbladder neck from the gallbladder bed of the liver before transecting the cystic artery and duct

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 Calots triangle.

Once the Calots 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.

The cystic duct and the GB neck and infundibulum together looks like Lord Ganeshas trunk and head (or elephants trunk and head) respectively and so also called as Lord Ganeshas sign.

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 Hartmans 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.

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.

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



Most bile duct injuries or strictures occur as a result of cholecystectomy for symptomatic gallstone disease. The majority of these patients are young (4050 years), female, have a long life expectancy, and are in the most productive years of their life.

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 long-term success rate.


1.Timing of diagnosis - Intra-operative - Early post-op - Late post-op

2.Extent and level of injury

3.Patient presentation

4.Hospital setup


A multidisciplinary approachThe team consisting of experienced interventional radiologists, endoscopists, and surgeons, coordinated by an experienced hepatobiliary surgeon

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

"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.)


Early post-op period Sepsis /SIRSTreat with Broad spectrum antibiotics -Percutaneous biliary drainage - Percutaneous/operative drainage of bilomas

No hurry for surgical repair - friable tissue -retraction of small ducts

Next step- Pre-op cholangiography (to define anatomy)

Control bile leak with percutaneous stents

Delayed surgical repair

Late post-op periodStricturesCholangitisTreat with- Broad spectrum antibiotics

Urgent cholangiography

Biliary decompression -Transhepatic biliary drainage -Endoscopic drainage + stent Surgical repair

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


Intra-operatively, any suspicious biliary injury

1) Intra-op cholangiography +/- Careful dissection 2) Lap to open conversion is often necessary

Isolated, small, noncautery-based partial lateral bile duct injury Placement of a T tube

Injury involves 50% of the circumference of the bile duct wall

End-to-side choledochojejunostomy with a Roux-en-Y loop of jejunum should be performed


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.


SURGICAL REPAIRThe 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

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

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

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

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


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.


The management of postoperative biliary strictures following ductal injury depends on the degree of injury, the presence of stricture-induced complications, and the operative risk of the patient.

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


Suspected CBD injury during lap-cholecystectomy

Intra-op cholangiogram

Partial injury(30%) Roux en Y choledochojejunostomyComplete transection Roux en Y.Injury to isolated hepatic duct >3mm Reimplantation or reconstruction by Roux en Y hepaticojejunostomy