Aaron M. Williams, M1University of Kentucky

College of MedicineMIS Elective

I. Overview of LC and Biliary Injury

II. Laparoscopic Cholecystectomy (Procedure)

II. Biliary Anatomy

III. Biliary Injury Mechanisms and Classification

IV. Management of Bile Duct Injury

V. Prevention

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

LC has been associated with a higher incidence of IA bile duct injuries

LC—0.4 to 0.8% Traditional OC—0.1-0.3%

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.

Risk Factors◦ 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

◦ 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

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

(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

Clip Applier Straight Dissector Metzenbaum Scissors Grasper(s) Scalpel and Suture L-hook electrocautery Suction-irrigation device

(5mm and 10mm) Probe Extraction Bag Cholangiogram

Epigastric region, below XP

Mid-A, between 12th rib and ilium

Subcostal, Mid-Clavicular Umbilical

region

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.

◦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

--Mistaking the common bile duct for the cystic duct

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

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

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

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.

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

Only 25-33% 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

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.

Patient presents with… 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

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

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

1. Schawartz’s Principles of Surgery, 8th ed., The McGraw-Hill Companies, 2005.2. Blumgart L.H. Surgery of the Liver, Biliary Tract, and Pancreas, 4th edition.

Saudders Elseiver. 2007. 3. Nagral S. Anatomy relevant to cholecystectomy. J Min Acess Surg 2005; 1:53-58.4. Haney C. and Pappas T. Management of Common Bile Duct Injuries. Operative

Techniques In General Surgery. January 2008. 175-184. 5. Archer et al. Bile Duct Injury During Laparoscopic Cholycystectomy: Results of a

National Survey. Annals of Surgery. Volume 234, No 4, 549-559.6. Wudel, James et al. Bile Duct Injury Following Laparoscopic Surgery: A Cause for

Continued Concern, The Am Surg, June 2001, 67:557-565.7. Massarweh N. and Flum D. Role of Intraoperative Cholangiography in Avoiding Bile

Duct Injury. J. Am. College of Surgeons. Vol 204, No. 4. April 2007.8. Lau et. All. Management of Bile Duct Injury After Laparoscopic Cholecystectomy: A

Review. ANZ J Surg 80 (2010) 75–819. Mortele, Koenradd et al. Anatomic Variants of the Biliary Tree: MP Cholangiographic

Findings and Clinical Applications, Am J of Roent, August 2001; 177:389-394.10. Ragozzino, Alfonso et al. Value of MR Cholangiography in Patients with Iatrogenic

Bile Duct Injury After Cholecystectomy. Am J of Roent, December 2004; 183:1567-1572.

11. Khalid, Tahir et al. Using MR Cholangiopancreatography to Evaluate Iatrogenic Bile Duct Injury, Am J of Roent, December 2001; 177:1347-1352.