Yemeni-Turkish Surgical Congress, 30-31 May 2012, Sana’a
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Transcript of Yemeni-Turkish Surgical Congress, 30-31 May 2012, Sana’a
Yemeni-Turkish Surgical Congress, 30-31 May 2012, Sana’a
Surgical management of bile duct injuries
Sinan YOL, M.D. General & Gastrointestinal Surgeon
Aim of the laparoscopic cholecystectomy
• Surgey (TODAY)Uncomplicated
Work (NEXT WEEK)
Aim of the laparoscopic cholecystectomy
Surgery (TODAY)Complicated / Injury
Long hospital stayRepeated investigations like USG and ERCPRadiologic interventionsRe-operationsEven liver transplantation
Bile duct injury
• Prevention should be the main point (much more important than the treatment)
• ALL laparoscopic cholecystectomies ARE difficult!– None of them is easy!
• If injury occurred, …who should treat it?when should it be treated?how should it be treated?
Bile duct injuryclassification (bismuth ve strasberg)
Treatment
If possible, diagnose the injury during the surgery!
When you realised that there is an injury, ASK for HELP!If possible do not try to repair, even you are experienced.
An experienced and FRESH surgeon should repair the injury.
If it is impossible AND it is a difficult injury that you can not treat, place catheters and refer the patient.
Intraoperative repair
Conversion! We do not like and do laparoscopic repair, if it is not so simple.
There is no ‘Tissue Lost’, primary repair over T-tube???stricture rate is high!!!
There is ‘Tissue Lost’, biliodigestive anastomosis:choledocoduodenostomy / hepaticojejunostomy
Intraoperative repair
Intraoperative repair
How long you should keep the T-tube?
Previously it was 6 months to 1 year.
Now, after 2 or 3 week, we do ERCP and place plastic stents (if possible more than one).
Post-operative diagnosed injury
Operation detail is important.
It is very common that each surgeon says there was an anomali which is not true.
Variations:
Post-operative diagnosed injury
Real anomali
Post-operative diagnosed injury
Biliary leak OR obstruction (type of injury)
Physical examination (treat the patient, not laboratory values!)
There is bilioma / sepsis or notaccompanying injury?
Post-operative diagnosed injury
First control the leak (percutaneous catheter placement, re-laparoscopic drainage, open surgery, nasobiliary drainage etc.) and treat the peritonitis (or even sepsis).
If the fistula is under control, give time for inflammation.
Then try to diagnose the type of injury (MRCP, fistulography, ERCP, PTC)
Diagnose
Diagnose
40 y old, femalePreoperative lab values N
POD 3, Bilirubin increased
USG minimal dilated bile ductEndoUSG : choledocholithiasis
ERCP : stone extirpated
Diagnose
Leak from ductus cysticus
(Strasberg A)
Diagnose and treatment
Leak from ductus cysticus (Strasberg A)
Nasobiliary drainage
Diagnose
ERCP
Complete obstruction
Diagnose
PTC (Strasberg E2)
Diagnose
MRCP
(Strasberg E3)
Diagnose
Arteriography
(RHA injury)
Surgical repairCholedocho-choledochostomy
Surgical repair Choledocho-duodenostomy
Surgical repair Hepatico-jejunostomy (Roux-en-Y)
Surgical repair Double lumen hepatico-jejunostomy (Roux-en-Y)
Surgical repair Formation of one anastomosis
Surgical repair left hepatic duct anastomosis
(Segment III / Hepp-Couinaud)
Surgical repair Intrahepatic cholanjio-jejunostomy (Longmire)
Surgical repair Permanent access hepatico-jejunostomy
Percutaneous repair
Endoscopy through permanent access
Percutaneous baloon dilation
Surgical repair Fistulo-jejunostomy
Simple and short duration surgery for selected
patients