Presentation about biliary injury Hepatobiliary surgery

1. INJURY TO THE
BILIARY TRACT
By Dr Ashraf Adam

3. Gallbladder
• Injuries to the gallbladder are uncommon
• Penetrating trauma
• Gunshot or stab wounds
• Medical procedures
• Liver biopsy or surgery
• Nonpenetrating trauma
• Contusion, avulsion, laceration, rupture, or traumatic
cholecystitis.
• Regardless of the etiology of gallbladder injury, the treatment
of choice is cholecystectomy.

4. Extrahepatic Bile Ducts
• Penetrating trauma
• Iatrogenic
• Cholecystectomy
• Common bile duct exploration,
• Gastrectomy,
• Liver resections.

5. Bile duct injury after
cholecystectomy
• Accounts for 80% of iatrogenic biliary injuries
• The incidence of bile duct injury during cholecystectomy
is about 0.2%
• These injuries are among the most feared and litigated
complications in surgery, and can result in sig nificant
morbidity

6. Factors associated with bile duct
injury during cholecystectomy
• Acute or chronic inflammation
• Obesity
• Anatomic variations
• Surgical technique
• Inadequate exposure or
• Failure to correctly identify structures before ligating or dividing them
• Excessive cephalad retraction of the gallbladder
• Careless use of electrocautery
• Dissection deep into the liver parenchyma

7. Techniques to avoid injury to the
bile ducts during cholecystectomy
• The use of an angled, 30° or 45° laparoscope instead of
an end-viewing camera will help visualize the anatomic
structures, in particular those around the triangle of Calot
• The routine use of intraoperative cholangiography during
every cholecystectomy
• Obtaining the critical view of safety during lap
cholecystectomy

9. Classification
of biliary injures
STRASBERG
CLASSIFICATION

10. Complications
• Biliary fistula with electrolyte imbalance.
• Biliary peritonitis,
• Septicemia.
• Subphrenic abscess formation.
• Biloma formation.
• Severe malnutrition
• Late-biliary cirrhosis, portal hypertension.

11. Presentation
• Bile duct injures may be identified intraoperative but
usually manifested in the post operative period
• Bile leak tends to manifest earlier than stricture and its
associated jaundice
• Intraoperative bile leakage, recognition of the correct
anatomy, or an abnormal cholangiogram led to the
diagnosis of a bile duct injury

12. • In those that go unrecognized at the time of surgery, more
than half will re-present within the first month
postoperatively, though some can present months or
years later with strictures, cholangitis, or cirrhosis
• Leak : fever abdominal pain jaundice or bile leak through
the incision or the drain or with complications of an
intraabdominal collection
• Obstruction or stricture should be suspected in patients
with progressive elevations of liver function tests or
jaundice after cholecystectomy. CT scan or ultrasound
can demonstrate the dilated part of the

13. Investigations
• LFT, coagulation profile
• US abdomen,CT scan
• ERCP is useful if injury is only partial where stenting can also
be done.
• PTC is the investigation of choice to identify site, nature,
extent of stricture. It also facilitates drainage and stenting.
• HAIDA scan
• MRCP may be useful to identify ductal anatomy.

19. Management
• The management of bile duct injuries depends on the
type, extent, and level of the injury, as well as the timing
of its diagnosis.
• Initial proper treatment of bile duct injury can avoid the
development of further complications or bile duct
strictures.
• If an injury is discovered that exceeds the capacity of the
available surgical expertise, the patient should be
transferred to a tertiary care center

20. Management of biliary duct
injury on table
• The goals of immediate treatment of bile duct injury are
maintenance of ducts length, elimination of any bile leak and
creation of tension free repair
• Conversion into open surgery
• lntraoperative cholangiogram should be done.
• Isolated hepatic duct injury less than 3 mm in size that
draining a single segment can be ligated
• More than 3 mm in size should be reimplanted or Roux-en-Y
hepaticojejunostomy should be done

21. • Partial injury of CBD less than 50% of circumference is
treated with primary repair with a T-tube in place T-tube
can be placed through it as if it were a formal
choledochotomy.
• Extensive injury more than 50% of the circumference or
cautery injury or complete CBD transection biliary-enteric
continuity should be restored according to the site of
injury and the size of the lost segment.

22. • When the defect is less than 1cm and not near the
bifurcation end to end anastomoses of the bile duct with
T tube placement in a different choledochotomy not in the
anastomoses sit
• More commonly, injuries occur adjacent to the bifurcation
or involve more than a 1-cm defect between the ends of
the bile duct. These injuries require reanastomosis to the
gastrointestinal tract.
• Roux-en-Y choledochojejunostomy or Roux-en-Y
hepaticojejunostomy with transanastomotic stenting

23. Management of bile duct injury
identified at a later period
1. Control of infection, limiting inflammation
• Parenteral antibiotics
• Percutaneous drainage of periportal fluid collections
2. Clear and thorough delineation of entire biliary anatomy
• MRCP or PTC
• ERCP (especially if cystic duct stump leak is
suspected)

24. 3. Reestablishment of biliary-enteric continuity
• Tension-free, mucosa-to-mucosa anastomosis
• Roux-en-Y hepaticojejunostomy
• Long-term transanastomotic stents if bifurcation or higher is
involved

25. • Patients with bile duct stricture present with progressive
elevation of liver function tests or cholangitis.
• The initial management usually includes endoscopic
attempts at dilation or stenting.
• Balloon dilatation.
• Self-expanding metal or plastic stents
• Definitive treatment of refractory biliary strictures entails
resection of the affected segment and reconstruction with
a biliary-enteric anastomosis

26. Outcome
• The best results coming when the injury is recognized
immediately and repaired by an experienced biliary tract
surgeon.
• The worst results are seen in patients with many operative
revisions and in those who have evidence of liver failure or
portal hypertension.
• In the most severe cases, patients with refractory
strictures and deteriorating liver function may become
candidates for liver transplant.

27. References
• SRB's Manual of Surgery 6th Edition
• Schwartz’sPrinciples of Surgery 11th Edition
• Sabiston Textbook of Surgery 20th Edition