Billiary Injury

8/7/2019 Billiary Injury

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Open Cholecystectomy: 0.2%

Laproscopic cholecystectomy 0.6 %


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Poor visualisation

Difficult or Varriant anatomy

Unproper techieques


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Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Mortele, Koenradd et al.,Am J of Roent,August 2001.

Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm

with common hepatic duct (15-25%); F,G,H. Medial cystic duct insertion (10-

17%). Uncommon variants: C. High fusion with hepatic duct; D. Fusion at right

hepatic duct; F. No cystic duct.


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Blumgart LH. Surg Clin N Am. 1994.74.4


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Common biliary variant in 34-year-old woman with recurrent

cholestasis after cholecystectomy. MRC showing triple confluence of

right anterior duct (small arrowhead), right posterior duct (small arrow),

and left hepatic duct (large arrowhead). Cystic stump (large arrow).


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Uncommon biliary variant in 62-year-old woman after

cholecystectomy. MRC showing high insertion of cystic duct

(arrow) into common hepatic duct (arrowhead).


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Mis identificatin: Ecission,incission

,laceration and cliping

Electrocautry: thermal injury causes stricture

Mechaincal trauma


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Lahey Clinic, Burlington, MA.1994


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Bismuth classification of bile duct strictures



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(A) cystic duct leaks or leaks from ducts in

liver beds

(B) occlusion of part of biliary tree almost

aberrant RHD (C) transection without ligation of aberrant

RHD

(D) Lateral injuries to major bile ducts

(E) sub devided as per bismuth classification


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Neuhaus P, Humbolt Univ. of BerlinBJS.2005.92. 76-82


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CLINCALY PATIENTS R DEVIDED IN 3 GROUPS

(1) Detected Peroperatively

(2)Delayed Presentation >24 hours averagely

7 days

Long symptoms free interval 1 month to 1

year


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General malaise

Nausea

Vomiting

Anorexia

Abdominal pain

Low grade fever

With peritonitisWith obstrctive jaundice


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Present with obstructive jaundice due to

stricture development


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Ultrasound with subsequent aspiration of

collection

MRCP

ERCP

PTC

CT


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Is there subhepatic abscess or collection?

Is there ongoing bile leakage ?

What is the level of biliary injury ? Are there associated vascular injuries /

Is there evidence of lobar atrophy ?


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An ERC of same patient showing a leak

from the cystic duct stump (arrow). Note

the filling of the pancreatic duct.

Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

CT scan of patient with bile leak aftercholecystectomy. The short arrows

indicate the intraperitoneal collections.

Both air and bile is seen in the gallbladder

bed (long arrow) as is a surgical clip.


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Bile Duct StrictureBile duct stricture at cystic duct origin in 17-year-old boy who presented with

obstructive jaundice 1 month after laparoscopic cholecystectomy that wasconverted to open cholecystectomy because of difficulty in extracting impacted

cystic duct calculus.

Khalid, Tahir et al.,Am J of Roent, December 2001; 177:1347-1352.

MRCP showing moderate intrahepatic and

extrahepatic biliary dilatation caused by short tight

stricture (arrow) of common bile duct where cystic

duct origin once began. Intact distal bile duct

segment is seen below stricture.

PTC showing stricture (arrow) that was

subsequently balloon-dilated.


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Excisional Injury


Excision injury with ligation in 35-y/o woman who presented 1

week after laparoscopic cholecystectomy with right upperquadrant pain and jaundice.

ERCP image showing distal one third of bile duct

with abrupt cutoff (arrow) and multiple surgical

clips in subhepatic area.

MRCP showing moderate intrahepatic biliary

dilatation and cutoff approx. 1 cm distal to

bifurcation caused by ligation injury. Segment of

extrahepatic bile duct 1.8 cm long is missing

(arrows).


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Cystic Duct Leak


ERCP image confirming subhepatic bile leak (arrow).MRCP showing fluid collection (curved

arrows) adjacent to cystic duct remnant

(straight arrow).


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Right Aberrant Duct Excision

Park, Mi-Suk et al.,Am J of Roent, December 2004.

Hepatobiliary

scintigram obtained 90

min after injection of

iminodiacetic acid, 2

months after MRCP,

shows photon-defect

area (arrows) in right

lobe of liver.

56-y/o man with mild abdominal discomfort for 21 days after laparoscopic cholecystect

Coronal MRCP obtained

before mangafodipir

trisodium (MnDPDP)enhancement with thick-

slice half-Fourier RARE

sequence showing

mildly dilated and

disconnected right

posterior duct (arrow).

Max-intensity image from

coronal 3D volumetric

interpolated T1-weightedgradient-echo image

obtained 30 min after

injection of MnDPDP

showing opacification of

right posterior duct (arrow)

suggesting possible partial

ligation of aberrant right

posterior duct.

ERCP image with

right posterior duct

not seen.


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Stricture with Cystic Duct Leak

Park, Mi-Suk et al.,Am J of Roent, December 2004.

ERCP image showingpartial stricture (thin arrow)

of common bile duct with

bile leakage (thick arrow).

35-y/o man with abdominal pain and fever for 10 days after laparoscopic cholecystect

Coronal MRC obtainedbefore mangafodipir

trisodium (MnDPDP)

enhancement with thin-

section half-Fourier RARE

sequence shows narrowing

of common bile duct (thin

arrow) with abnormal fluid

collection (thick arrow).

Coronal 3D volumetricinterpolated T1-weighted

gradient-echo image obtained 30

min after injection of MnDPDP

showing enhanced extrahepatic

duct, in spite of a narrowing

segment (thin arrow), with

extravasation of contrast agent

(thick arrow).


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Biliary catheter decompression bile tract and

to control bile leaks

Percutaneuos drainage of bile collection


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Balloon dilation and stents for strictures

T-Tube placement

Primary end to end anastomosis

Biliary anastomosis with jejunal loops


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Blumgart LH, Surg of the Liver & Biliary tract, 1994


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Blumgart LH : Surg N Am; 1994, vol. 74 no. 4

A. Percutaneous trans-enteric

B. Percutaneous transhepatic

C. U tube

D. Internal small silicone stentanchored to mucosa


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Blumgart LH,Surgery of the Liver and Biliary Tract, 1994

Burried Subcutaneous

Stoma, marked by clip

Open skin stoma

Warko Karnadihardja-BDG


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Preventive measures

Use 30 degree high quality image

laproscope

Apply cephalic traction to fundus and

lateral traction to infundibulum

Expose critical view of safety

Dissect cystic duct where it joins

G.bladderPerform routine intra operative

cholangiography

Billiary Injury

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