Bile Duct Injuries Prevention & Management

Dr.S.EaswaramoorthyMS FRCS(Eng) FRCS (Glas) FRCS (Edin)

Head of Dept of Minimal Access Surgery

Lotus hospital, Erode

Examiner, RCS of Edinburgh

Executive Member, South Zone IAGES

World’s First Lap Chole

Phillipe Mouret-1987

Erich Muhe-1985

They made it feasible, let us make is safe!....

Risk of Bile Duct Injury

•More Often•Happens in 0.5% cases

•Major injury•More proximal ducts

1.6 million Lap chole in Medicare beneficiaries-1992-1999

Lap Chole is the answer, but…

Learning Curve Vs Real Danger

Why more BDI?

Upward retraction of fundus

So What? 1. Upward retraction of fundus

2. Down and out retraction of Hartmann’s

Assistant’s Left hand in Open CholeSurgeon’s Left hand in Lap chole

Visual Perceptual Illusion

You see What U want to See

Pathogenesis of Bile Duct Injury IMisidentification of Bile duct as cystic duct

Classical BDI during Lap Chole

Disaster

Dangerous Anatomy

Dangerous Pathology

Bile duct is cut twice to remove the GB

Pathogenesis of Bile Duct Injury IIDangerous Technique!!

1. Dissection Injury

2. Traction injury

3. Diathermy Injury

Pathogenesis of Bile Duct Injury IIDangerous Technique!!

1. Dissection Injury

2. Traction injury

3. Diathermy Injury

Pathogenesis of Bile Duct Injury IIDangerous Technique!!

1. Dissection Injury

2. Traction injury

3. Diathermy Injury

1.Trouble Prevention I

1. Follow the Steps of Safe Cholecystectomy– Identify GB-Cystic duct junction

• Elephant Trunk sign

– Rouviere’s Sulcus– Critical View

2. Look for Cues of bile duct injury

3. Cholangiogram

1.Identify Junction of Cystic duct and GBInfundubular Technique

Elephant Trunk Sign

99% Cholecystectomy is better than101% cholecystectomy!

Beware: Hidden cystic duct syndrome

2.Rouviere’s Sulcus

Extra biliary reference point for safe navigation!

Are we One Hundred Percent Sure?!3.Strasburg’s Critical View of Safety

Trouble Prevention II

1. Steps to avoid bile duct injury– Identify GB-Cystic duct junction

• Elephant Trunk sign

– Rouviere’s Sulcus– Critical View of Safety

2. Look for Cues of bile duct injury

Red Flag Signs of BDI

• Unclear Anatomy/Anomaly• Dangerous pathology

– Acute Cholecystitis

– Mirrizi’s Syndrome

– Impacted stone at Cystic duct

– Large stone in Hartmann’s pouch

• Clips are small for the duct!• Unexplained bile leak!!• Unusual field of vision

– More Duodenum, Less Liver

Golden yellow

Trouble Prevention III

1. Steps to avoid bile duct injury– Identify GB-Cystic duct junction

• Elephant Trunk sign

– Rouviere’s Sulcus

– Critical View

2. Look for Cues of bile duct injury

3. Cholangiogram

When in doubt,Consider Cholangiogram

IndicationUnclear AnatomySuspected Bile duct stone

May not prevent BDI but could aid its early recognition!

2.Trouble Management

• How to recognize BDI?• What Investigations?• When to intervene?• Which repair?

Classical BDI during Lap Chole

1.How to recognize BDI

• Intra operatively(25%)– Don’t panic!– Drain/Control of sepsis– Refer

• Post operatively– Pain– Bile leak

• Pain, Bile in the drain, signs of peritonism

– Biliary Obstruction• Abnormal LFT, Jaundice, cholangitis

2.Role of Imaging in BDI1. US/CT abdomen

– To look for any collection/ Guided drainage

2. HIDA scan– Confirms leak but fail to give anatomic detail we need

3. PTC– To visualize the proximal ducts and assess the grade the injury

– Stenting?

4. MRCP– Non invasive Test of Choice to assess the grade of injury

– Both proximal and distal ducts could be seen and leaks also could

be identified

5. ERCP– Mainly delineate distal ducts only

– Mainly for Therapeutic purpose /operator dependent

3.Trouble Management

Type Strasburg Classification of BDI

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

B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts

C Transection without ligation of the aberrant right hepatic duct

D Lateral injuries to major bile ducts

E Subdivided as per Bismuth’s classification into E1 to E5

US/CT Guided DrainageERCP and Stenting

A D

Bilioma is prone for infection and bile can destroy tissues, so act quick!

MRCP & then ERCP

ERCP/Sphincterotomy/Stenting

3.Trouble Management

Type Strasburg Classification of BDI

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

B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts

C Transection without ligation of the aberrant right hepatic duct

D Lateral injuries to major bile ducts

E Subdivided as per Bismuth’s classification into E1 to E5

B Rare

3.Trouble Management

Type Strasburg Classification of BDI

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

B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts

C Transection without ligation of the aberrant right hepatic duct

D Lateral injuries to major bile ducts

E Subdivided as per Bismuth’s classification into E1 to E5

CRare

Types of Major Bile Duct Injuries

Type E

Bismuth Classification of Bile Duct Stricture

1 Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm

2 Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm

3 Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved

4 Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct

5 Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct

E 1 & 2 E3 E5E4

MRCP & ERCP in BDI

35 yr lady with classical post lap chole

MRCP can see both above and below the level of biliary obstructionSo no need for PTC! Excision injury of bile duct

4.Which repair & When?

• Hepaticojejunostomy– Let us leave it to the experts…– 1st time is the best – <72 hr or wait till 6 weeks

• End to end repair over T tube: seldom done

Bile duct injuries associated with Lap chole.Timing of repair and long term outcomeArch Surgery 2010 : 145 (8): 757-763

Hepatico jejunostomy-1

Hepatico jejunostomy-2

Tension-free and widely patent, with a mucosa-to-mucosa anastomosis.Ensure well-vascularized bile ducts and use monofilament absorbable sutures

Conclusion

• Let us adhere to safety rules of Lap chole

• Bile duct injuries are disastrous

• Management of BDI needs Specialist