Bile duct injury during laparoscopic cholecystectomy

download Bile duct injury during laparoscopic cholecystectomy

of 35

Embed Size (px)

description

laparoscopic bile duct injury mechanism of injury prevention and management

Transcript of Bile duct injury during laparoscopic cholecystectomy

  • 1. Bile Duct Injuries Prevention & Management Dr.S.Easwaramoorthy MS 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

2. Worlds First Lap Chole Phillipe Mouret-1987 Erich Muhe- 1985 They made it feasible, let us make is safe!.... 3. 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 4. Why more BDI? Upward retraction of fundus 5. So What? 1. Upward retraction of fundus 2. Down and out retraction of Hartmanns Assistants Left hand in Open Chole Surgeons Left hand in Lap chole 6. Visual Perceptual Illusion You see What U want to See 7. Pathogenesis of Bile Duct Injury I Misidentification 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 8. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury 9. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury 10. Pathogenesis of Bile Duct Injury II Dangerous Technique!! 1. Dissection Injury 2. Traction injury 3. Diathermy Injury 11. 1.Trouble Prevention I 1. Follow the Steps of Safe Cholecystectomy Identify GB-Cystic duct junction Elephant Trunk sign Rouvieres Sulcus Critical View 1. Look for Cues of bile duct injury 2. Cholangiogram 12. 1.Identify Junction of Cystic duct and GB Infundubular Technique Elephant Trunk Sign 99% Cholecystectomy is better than 101% cholecystectomy! Beware: Hidden cystic duct syndrome 13. 2.Rouvieres Sulcus Extra biliary reference point for safe navigation! 14. Are we One Hundred Percent Sure?! 3.Strasburgs Critical View of Safety 15. Trouble Prevention II 1. Steps to avoid bile duct injury Identify GB-Cystic duct junction Elephant Trunk sign Rouvieres Sulcus Critical View of Safety 1. Look for Cues of bile duct injury 16. Red Flag Signs of BDI Unclear Anatomy/Anomaly Dangerous pathology Acute Cholecystitis Mirrizis Syndrome Impacted stone at Cystic duct Large stone in Hartmanns pouch Clips are small for the duct! Unexplained bile leak!! Unusual field of vision More Duodenum, Less Liver Golden yellow 17. Trouble Prevention III 1. Steps to avoid bile duct injury Identify GB-Cystic duct junction Elephant Trunk sign Rouvieres Sulcus Critical View 1. Look for Cues of bile duct injury 2. Cholangiogram 18. When in doubt, Consider Cholangiogram Indication Unclear Anatomy Suspected Bile duct stone May not prevent BDI but could aid its early recognition! 19. 2.Trouble Management How to recognize BDI? What Investigations? When to intervene? Which repair? Classical BDI during Lap Chole 20. 1.How to recognize BDI Intra operatively(25%) Dont 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 21. 2.Role of Imaging in BDI 1. US/CT abdomen To look for any collection/ Guided drainage 1. HIDA scan Confirms leak but fail to give anatomic detail we need 1. PTC To visualize the proximal ducts and assess the grade the injury Stenting? 1. 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 1. ERCP Mainly delineate distal ducts only Mainly for Therapeutic purpose /operator dependent 22. 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 Bismuths classification into E1 to E5 US/CT Guided Drainage ERCP and Stenting A D Bilioma is prone for infection and bile can destroy tissues, so act quick! 23. MRCP & then ERCP ERCP/Sphincterotomy/Stenting 24. 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 Bismuths classification into E1 to E5 B Rare 25. 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 Bismuths classification into E1 to E5 C Rare 26. Types of Major Bile Duct Injuries Typ e 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 27. MRCP & ERCP in BDI 35 yr lady with classical post lap chole MRCP can see both above and below the level of biliary obstruction So no need for PTC! Excision injury of bile duct 28. 4.Which repair & When? Hepaticojejunostomy Let us leave it to the experts 1st time is the best