1. Biliary Injuries During Laparoscopic Cholecystectomy
Aaron M. Williams, M1
University of Kentucky
College of Medicine
MIS Elective

2. Focus Overview of LC and Biliary Injury
Laparoscopic Cholecystectomy (Procedure)
Biliary Anatomy
Biliary Injury Mechanisms and Classification
Management of Bile Duct Injury
Prevention

3. History of LC Widespread acceptance in early 1990’s
“Gold Standard” treatment for gallbladder removal
Approx. 750,000 LCs are performed each year in the U.S.
General advantages of LC—MIS approach
Reduced hospitalization
Improved recovery time
Decreased PO pain
Improved cosmesis
Reduced cost

4. The Problem
LC has been associated with a higher incidence of IA bile duct injuries
LC—0.4 to 0.8%
Traditional OC— %
Association:
Increased mortality and morbidity
Reduced long-term survival
Reduced quality of life
Infrequent—but among the leading sources of malpractice claims against surgeons.
Between 34% and 49% of surgeons are expected to cause such an injury during their career.
Awareness and preventative methods are of clinical importance to surgeons.

5. Risk Factors and Mechanism
Anatomical
Anatomical variations (biliary and vasculature)
Bleeding, scarring, obesity
Laparoscopic
Lack of Depth Perception, Tactile Feedback, Full Manual Maneuverability
Improper surgical approach
Improper Lateral retraction (insufficient or excessive)
0 degree scope
Approach plane too deep
Lack of conversion to OC during difficult cases

6. Mechanism of injury Initially…Surgeon’s Learning Curve –Steady
Anatomical Misidentification: excision, incision, or transection of biliary anatomy
Injuries: common bile duct, common hepatic duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments
Anatomical variations (biliary and vasculature)
Electrocautery, thermal injury: stricture of CBD or hepatic ducts, bile leak
Mechanical trauma: stricture of the biliary ducts, bile leaks
Improper surgical approach

7. Operating Room Setup
Reverse Trendelenburg (30 degrees) with left arm out at 90 degrees relative to the body’s axis
Titled left 15 degrees after optical trocar placement

8. Instrumentation Clip Applier Straight Dissector Metzenbaum Scissors
Grasper(s)
Scalpel and Suture
L-hook electrocautery
Suction-irrigation device (5mm and 10mm)
Probe
Extraction Bag
Cholangiogram
(1)--10 mm optical trocar (umbilical region)
(2)--5 mm operating trocars (subcostal ports)
- (1)--5 mm operating trocar (epigastric region)
- 10 mm 30 degree laparoscope

9. Trocar Placement Epigastric region, below XP Subcostal, Mid-Clavicular
Umbilical region
Mid-A, between 12th rib and ilium

10. Biliary Anatomy a. Right hepatic duct. b. Left hepatic duct.
c. Common hepatic duct.
d. Portal vein.
e. Hepatic artery.
f. Gastroduodenal artery.
g. Right gastroepiploic artery.
h. Common bile duct.
i. Fundus of the gallbladder.
j. Body of the gallbladder.
k. Infundibulum.
l. Cystic duct.
m. Cystic artery.
n. Superior pancreaticoduodenal artery.
Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

11. Remember…Mechanism of injury
Anatomical Misidentification: excision, incision, or transection of biliary anatomy
Injuries: common bile duct, common hepatic duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments
Anatomical variations (biliary and vasculature)
Electrocautery, thermal injury: stricture of CBD or hepatic ducts, bile leak
Mechanical trauma: stricture of the biliary ducts, bile leaks

12. Classic Laparoscopic Injury
--Mistaking the common bile duct for the cystic duct

13. Thermal Injuries Lahey Clinic, Burlington, MA.1994
Inappropriate use of electrocautery near biliary ducts
May lead to stricture and/or bile leaks
Mechanical trauma can have similar effects
Lahey Clinic, Burlington, MA.1994

14. Strasburg Classification
Type A Cystic duct leaks or leaks from small ducts in the liver bed
Type B Occlusion of a part of the biliary tree, almost invariably the
aberrant right hepatic ducts
Type C Transection without ligation of the aberrant right hepatic
ducts
Type D Lateral injuries to major bile ducts
Type E Subdivided as per Bismuth classification into E1 to E5

15. Strasburg Classification, cont’d
E: injury to main duct (Bismuth)
E1: Transection >2cm from confluence
E2: Transection <2cm from confluence
E3: Transection in hilum
E4: Seperation of major ducts in hilum
E5: Type C plus injury in hilum

16. Lau classification (2007)
Type 1 Leaks from cystic duct stump or small ducts in liver bed
Type 2 Partial CBD/CHD wall injuries without (2A) or with (2B)
tissue loss
Type 3 CBD/CHD transection without (3A) or with (3B) tissue loss
Type 4 Right/Left hepatic duct or sectoral duct injuries without (4A) or with (4B) tissue loss
Type 5 Bile duct injuries associated with vascular injuries
CBD, common bile duct; CHD, common hepatic duct.

17. Lau Possible Mechanisms
1– Insecure closure of cystic duct; too deep dissection into
gallbladder bed
2 – Incision of CBD instead of cystic duct for operative Cholangiogram; Clipping of CBD but recognized; Laceration of cystic duct/CBD junction; Diathermy injury to CBD/CHD
3 – CBD mistaken as cystic duct, with CBD/CHD transected or
Resected; Diathermy injury
4 – Right HD or sectoral duct mistaken for cystic duct
5 – Right hepatic artery mistaken for cystic artery; Diathermy or clip injuries to right hepatic artery

18. Intraoperative Detection
Only % of injures are recognized intraoperatively
If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury)
If not experienced, perform the cholangiogram laparoscopically with intent of referring patient (placement of drains)
Consult an experienced hepatobiliary surgeon
Quicker the repair, the better the outcome!!!
Acute Management
Biliary catheter for decompression of biliary tract and control of bile leaks
Percutaneous drainage of intraperitoneal bile collection

19. Post-Operative Detection Plan
Controlling sepsis, establish biliary drainage, postulate diagnosis, type and extent of the bile duct injury.
Broad-spectrum antibiotics
No need for an urgent laparotomy. Biliary reconstruction in the presence of peritonitis results a statistically worse outcome in patients.
No need for urgent with reconstruction of the biliary tree. The inflammation, scar formation and development of fibrosis take several weeks to subside.
Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.

20. BDI Management Patient presents with… Investigation
Vague abdominal pain, nausea, fever, jaundice, vomiting
Investigation
Ultrasonagraphy and CT (ductal dilatation and intra-abdominal collection)
Cholangiogram
ERCP—biliary anatomy and assess the injury
PTC—define biliary anatomy proximal to injury
MRCP—noninvasive (can miss minor leaks)
MR angiography—vascular injuries

21. Management of Bile Duct Injuries, Cont.
Corrective Treatment (Lao)
Endoscopic stenting for strictures
T-tube placement for minor lacerations
Primary duct-to-duct repair only if tension free anastomosis available
Biliary anastomosis with jejunal loop for major excisional injuries

22. Preventative Measures (Lao)
Attention to operative details (insufficient close or deep plane)
Stasberg’s critical view of safety
Appropriate Handling of Gallbladder
Careful use of diathermy
Recognition of Biliary and Vasculature Anomalies

23. Can BDIs be prevented?

24. Bibliography
Schawartz’s Principles of Surgery, 8th ed., The McGraw-Hill Companies, 2005.
Blumgart L.H. Surgery of the Liver, Biliary Tract, and Pancreas, 4th edition. Saudders Elseiver
Nagral S. Anatomy relevant to cholecystectomy. J Min Acess Surg 2005; 1:53-58.
Haney C. and Pappas T. Management of Common Bile Duct Injuries. Operative Techniques In General Surgery. January
Archer et al. Bile Duct Injury During Laparoscopic Cholycystectomy: Results of a National Survey. Annals of Surgery. Volume 234, No 4,
Wudel, James et al. Bile Duct Injury Following Laparoscopic Surgery: A Cause for Continued Concern, The Am Surg, June 2001, 67:
Massarweh N. and Flum D. Role of Intraoperative Cholangiography in Avoiding Bile Duct Injury. J. Am. College of Surgeons. Vol 204, No. 4. April 2007.
Lau et. All. Management of Bile Duct Injury After Laparoscopic Cholecystectomy: A Review. ANZ J Surg 80 (2010) 75–81
Mortele, Koenradd et al. Anatomic Variants of the Biliary Tree: MP Cholangiographic Findings and Clinical Applications, Am J of Roent, August 2001; 177:
Ragozzino, Alfonso et al. Value of MR Cholangiography in Patients with Iatrogenic Bile Duct Injury After Cholecystectomy. Am J of Roent, December 2004; 183:
Khalid, Tahir et al. Using MR Cholangiopancreatography to Evaluate Iatrogenic Bile Duct Injury, Am J of Roent, December 2001; 177: