Dr. Hung Ka Wai Ray Team 1 Hepatobiliary and Pancreatic

Surgery Prince of Wales Hospital

Laparoscopic cholecystectomy Standard treatment of symptomatic

gallstone disease > 750, 000 were performed annually in the

United States Less pain, fewer wound complication,

quicker recovery The only potential disadvantage is a higher

incidence of major bile duct injury [1], 0.3% open vs 0.6% laparoscopic

Bile duct injury is a very serious complication that lead to mortality, significant morbidity and impaired quality of life

Causes: Iatrogenic

Cholecysectomy (80-85%) [2]

Gastrectomy Pancreatectomy ERCP

Trauma Duodenal ulcer

Intraoperative Direct observation of a divided duct Bile in the operative field Abnormal intra-operative cholangiography

Postoperative Bile leak

Bile in the drain Biloma, biliary fistula, or bile ascites Bile peritonitis in severe cases

Biliary obstruction Obstructive jaundice Cholangitis

Bismuth Strasberg et al. Stewart et al. McMahon et al. AMA Neuhaus et al. Csendes et al. Hanover Lau and Lai Siewert et al. Cannon et al. Kapoor Sandha et al. EAES

Depend on the timing of recognition of the injury

Intraoperative vs postoperative recognition

Account for 25%–32.4% [3] First consult an experienced hepatobiliary surgeon Convert to laparotomy with cholangiography

Define the nature of the injury If expertise a/v

Immediate repair can minimize the morbidity Higher successful rate, fewer morbidty and mortality [4]

If expertise not a/v Injudicious attempts at exploration may cause further biliary

and vascular injury Subhepatic drain to prevent collection External biliary drainage Refer to a specialized hepatobiliary unit

Aim of management Control sepsis and limit inflammation Delineate the biliary anatomy and

associated vascular injury Re-establish the biliary enteric continuity

Fluid resuscitation Broad spectrum antibiotic Investigation

USG / CT to asses collection +/- drainage

Cholangiography ERCP PTC MRCP

CTA / MRA Incidence is around 16.7%-47%[6]

Most commonly involving the right hepatic artery Does not usually lead to early significant

complications Impact on bile duct injury [7]

Associated with increased intraoperative bleeding during repair

Difficult reconstruction Higher incidence of anastomotic stricture due to bile

duct ischamemia Delayed repair if VBI is present

According to the type of injury Surgery vs endoscopic treatment

Strasberg classification

Surgical treatment

A ERCP + sphincterotomy + stent

B Hepaticojejunostomy

C Hepaticojejunostomy

D Primary repair if small injury with no devascularization Hepaticojejunostomy if extensive injury

E Hepaticojejunostomy

Stricture Balloon dilatation and biliary stenting Hepaticojejunostomy has higher successful

rate Secondary biliary cirrhosis

Liver transplantation

[1] Acute bile duct injury. The need for a high repair. Surg Endosc 2003;17: 1351-1355

[2] Bile duct injuries during laparoscopic cholecystectomy: primary and long term results from a single institution. Surg Endosc 2007; 21: 1069-1073

[3] Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy.Factors that influence the results of treatment. Arch. Surg. 1995; 130: 1123–8.

[4] Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann. Surg 2005;241:786-90

[5] Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes, HBP2009, 11, 516-522

[6] Management and outcome of patinets with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004; 135: 613-8

[7] Management of bile duct injury after laparoscopic cholecystectomy: a review, ANZ J Surg 80 (2010) 75-81