Continuing Education Activity

Injuries to the bile duct are almost universally iatrogenic and occasionally are due to trauma. The most common procedure leading to bile duct injury is the laparoscopic cholecystectomy. Prior to the advent of laparoscopic cholecystectomy, open cholecystectomy was used and was associated with a 0.1 to 0.2 percent risk of bile duct injury. With the introduction of laparoscopic cholecystectomy, the incidence has increased to 0.4 to 0.6 percent. This activity illustrates the evaluation and management of bile duct injuries and the types of repair available and highlights the role of the interprofessional team in managing patients who undergo bile duct repair.

Objectives:

• Describe the anatomy of the biliary tree.
• Review the types of bile duct repair procedures available.
• Explain the classification of bile duct injuries.
• Summarize the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients undergoing bile duct repair.

Introduction

Injuries to the bile duct are almost universally iatrogenic[1] and may infrequently be due to trauma. The most common procedure causing a bile duct injury is laparoscopic cholecystectomy. Historically the incidence of bile duct injury while performing an open cholecystectomy was as low as 0.1% to 0.2%, but with the introduction of laparoscopic cholecystectomy, the incidence has increased to 0.4% to 0.6% of patients.[2] Laparoscopic cholecystectomy performed for acute cholecystitis and more so for gall bladder empyema or gangrenous cholecystitis, has a higher chance of bile duct injury.[3][4] Any major bile duct injury may result in significant morbidity, increased mortality, and financial burden on the patient.[5] These injuries should be prevented with meticulous technique and selective use of intraoperative cholangiography. The most common technique to repair major bile duct injuries is the Roux-en-Y hepaticojejunostomy (RYHJ).

Anatomy and Physiology

Biliary anatomy and its vascular supply can be variable, which may lead to inadvertent injury or confusion during reconstruction.

Normal Biliary Anatomy

Extra-hepatic right and left hepatic bile ducts join at the hilar plate anterior to the right portal vein to form the common hepatic duct(CHD) (1 to 4 cm long and approximately 4 mm in diameter), which becomes the common bile duct (7 to 11 cm long and 5 to 10 mm in diameter) after giving off the cystic duct to the gallbladder. The common bile duct enters the second portion of the duodenum through the sphincter of Oddi (a muscular structure that controls the flow of bile into the duodenum).

The common bile duct most commonly joins the main pancreatic duct outside the duodenal wall and traverses it as a single duct.

Cystic Duct Anatomy

Variations occur in as many as 40% of patients, and it is important to recognize these as they may predispose to a bile duct injury during surgery. Important variations include the cystic duct circling anterior or posterior to the common hepatic duct prior to its insertion (occurs in 5% of patients), cystic duct draining into a right posterior hepatic duct (occurs in 0.6% to 2.3% of patients), and accessory ducts of Luschka (occurs in 15 to 30% of patients).

Right Hepatic Ductal System

Normal anatomy is present in 57% of patients. The right hepatic duct is a union of the right anterior and posterior sectoral ducts in normal patients. Common variations include drainage of the right posterior sectoral duct into the left hepatic duct (occurs in 20% of patients); drainage of the right anterior sectoral duct into the left hepatic duct (occurs in 6% of patients); and low insertion of the right hepatic or right sectoral duct into the common hepatic or cystic duct (known to increase iatrogenic risk of common bile duct injury during laparoscopic cholecystectomy).

Left Hepatic Ductal System

Normal anatomy is present in 67% of the population and is described as the junction of the left lateral and medial sectoral ducts to form the left hepatic duct.

Biliary Blood Supply

The blood supply to the common bile duct and the common hepatic duct is provided by 2 small arteries that travel along the lateral borders of the ducts at the 9 and 3 o'clock positions. These are branches of the right hepatic and cystic arteries superiorly and the posterior superior pancreaticoduodenal and gastroduodenal arteries inferiorly. The 2 arteries unite and form a plexus on the surface of the bile ducts. The supra-duodenal common bile duct is the most prone to ischemia due to the relatively poor blood supply when compared to the distal common bile duct. Arterial variants are common, and consist of a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery.

Indications

The indications for bile duct repair are dependent on the mechanism, temporal recognition, and classification of the bile duct injury. The type of injury and it's time of recognition will determine if and when an operation is required.

The other occasions when these techniques come in handy is while performing elective surgeries for gall bladder cancer (requiring resection of hepatic ducts)[6], hepatic resections, or hepatic transplants.

Bismuth-Strasberg Classification 

This is the most common system used (Type A to E; E1 to E5)[7]

• Type A injuries are a cystic duct stump leak or a leak from a duct of Luschka
• Type B injuries are a transection of an aberrant right hepatic duct without a bile leak
• Type C injuries are a transection of an aberrant right duct with a bile leak
• Type D injuries are a partial common hepatic duct injury with a bile leak
• Type E injuries are a complete transection of a major duct and are further classified into:
  • E1: Common hepatic duct transection greater than 2 cm away from the confluence of the right and left hepatic ducts
  • E2: Common hepatic duct transection less than 2 cm away from the confluence
  • E3: Common hepatic duct transection at the confluence but the right and left hepatic ducts are still connected 
  • E4: Common hepatic duct transection at the confluence with separation of the right and left hepatic ducts
  • E5: Common hepatic duct injury with a concomitant clipped and transected aberrant right hepatic duct

Timing of Recognition (determines management)

Intraoperative recognition should typically prompt immediate surgical repair as this confers the best outcomes; however, less than 40% of bile duct injuries are recognized at the index operation. Stewart and Law reviewed bile duct repairs done by specialists and general surgeons and found that only 17% of patients repaired by the general surgeon had a favorable outcome.[8] Bile duct injuries should not be underestimated. If the surgeon is inexperienced, an intraabdominal drain should be placed, and the patient should be immediately transferred to a hepatobiliary specialist.

• Early postoperative biliary injury recognition (typically within 24 to 48 hours) in a stable patient without signs of sepsis may be repaired immediately.
• Late postoperative recognition should generally be managed by immediate control of the sepsis with delayed reconstruction in about 12 weeks.[9] This will require a preoperative workup to classify the extent of the injury and for operative planning. Imaging techniques used to evaluate the biliary tree include hepatobiliary iminodiacetic acid(HIDA) scan[10], magnetic resonance cholangiopancreatography (MRCP), ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC). ERCP and PTC are procedures capable of both diagnosis and treatments for biliary injuries. A CT scan of the abdomen is also valuable to detect a potential biloma in a patient with peritoneal signs and can also be used to guide a drainage catheter. Patients with completely transected bile ducts may benefit from PTC-guided biliary drainage catheters, which will provide a controlled biliary fistula until a definitive repair is plausible. Patients that present late with bile leaks should have the biloma drained in addition to an ERCP or MRCP to classify the lesion. If there is no complete transection of the bile ducts, an ERCP-guided endobiliary stent is useful to facilitate drainage into the duodenum as opposed to the peritoneal cavity.

The procedure recommended for specific injuries requiring operative repair: 

1. Accessory duct injury: If the injured duct is less than 3 mm, the duct can be ligated; if greater than 4 mm, it requires operative repair. Larger ducts typically tend to be sectoral ducts and require repair.
2. Thermal injury to a major duct: Requires a Roux-en-Y hepaticojejunostomy (RYHJ)
3. Lateral injuries to a major duct without thermal injury (Type D): Primary suture repair over a T-tube
4. CHD transections greater than 2 cm away from bifurcation and the injured segment is less than 1 cm long (Type E1): Can consider end to end anastomosis with a T-tube at a different site
5. CHD transections less than 2 cm from bifurcation (Type E2-E5): All require RYHJ
6. Any CHD transection with an injured segment more than 1 cm long: All require RYHJ

Contraindications

Absolute contraindications for an RYHJ are the same for other surgical procedures: the inability to tolerate general anesthesia. An intrahepatic proximal bile flow obstruction is also a contraindication to an HJ.

Relative contraindications include timing of operation in the early postoperative period and uncontrolled biliary sepsis.

Equipment

Standard laparotomy surgical equipment is required.

Specific for HJ:

• Self-retaining laparotomy retractor
• Closed suction drain
• Biliary stents
• Magnifying loupes for visualization of the small bile ducts to ensure a good approximation of mucosa when performing anastomosis
• Fluoroscopy set up for intraoperative cholangiogram

If expertise is available, consideration may be given to perform a minimally invasive repair(laparoscopic or robotic).

Personnel

• Anesthesiologist
• Operating surgeon
• Surgical technician
• First assistant
• Circulating nurse
• Interventional radiologist if preoperative PTC required
• Gastroenterologist if ERCP required
• Radiology technician for fluoroscopic assistance

Preparation

For delayed repair of a biliary injury, the biliary tree will have been thoroughly investigated with various modalities of cholangiography. The patient should be adequately treated for sepsis, bile leak, or biliary obstruction with antibiotics, IR-guided drainage or PTC/ERCP with biliary stenting and drainage. For high common duct injuries, percutaneous stents placed in the proximal injured bile ducts are a valuable tool for identification intraoperatively.

Preoperative area

• Hair removal in the surgical field may be performed with the use of clippers
• A perioperative antibiotic will be administered 30 minutes prior to incision
• An epidural catheter may be considered for perioperative pain control and limiting the use of intravenous narcotics 

Operating room

• Patient position: supine.
• Anesthesia: General with endotracheal intubation
• The abdomen will be prepped and draped in the usual sterile fashion

Technique

• The following describes an open repair of bile duct injury.

• Incision and exposure: A variety of incisions may be placed to accomplish the bile duct repair. The most commonly performed is the right subcostal incision. It provides adequate exposure. A “hockey stick” incision is the midline extension of the subcostal incision. Alternately, an upper midline incision may be utilized. Dissection is carried through the abdominal wall, and the peritoneal cavity is entered. The self-retaining laparotomy retractor is then placed, and the surrounding adhesions are taken down. The adhesions are typically significant around the injured bile duct and must be lysed to completely mobilize and free up the quadrate lobe (segment IVb).

• Complete the cholecystectomy if not already done

• All visualized clips are removed, and the bile ducts are confirmed with the help of needle aspiration of bile. A cholangiogram is performed in the ducts proximal to the injury to visualize all segments of the liver and identify aberrant bile duct anatomy.

• A Kocher maneuver is performed (release the lateral attachments to the second portion of the duodenum which is then reflected medially to expose the posterior duodenum, pancreas, and retroperitoneum). This will facilitate exposure of the distal common bile duct stump which will be closed utilizing a continuous running permanent suture.

• Exposure of the left hepatic duct (LHD): The hilar plate (extension of Glisson’s capsule from the liver onto the hepatic ducts) is incised anteriorly to the LHD thus lowering and facilitating exposure of the duct.

• Exposure of the right hepatic duct (RHD): Glisson's capsule is incised at the base of segment IVb thus exposing the confluence of the right and left hepatic ducts. This can be easily done by continuing the plane already created when the LHD was exposed. This can be continued toward segment V exposing the right anterior and posterior sectoral ducts. Right ductal anatomy can be identified in an easier fashion if a preoperative percutaneous transhepatic biliary stent was placed within the duct.

• Preparation of bile duct for anastomosis: Depending on the classification of injury and its proximity to the hilar plate, the repair technique is chosen. In cases where there is a distal transection greater than 2 cm away from the confluence (E1 injury), the remaining common duct may be debrided and used for the hepaticojejunostomy. For patients with more proximal injuries without separation of the right and left hepatic duct communication (E2-E3), the Hepp-Couinaud approach can be used. This involves incising the LHD horizontally with extension and sometimes across the confluence to the RHD in preparation for a hepaticojejunostomy.[11] For injuries that completely separate the right and left biliary systems, 2 options are available; either separate right and left biliary-enteric anastomoses are performed, or if the 2 ducts are within 1 cm of each other, they can be approximated to form one common channel.

• Creation and preparation of the Roux limb: The jejunum is divided with a linear stapler 30 cm distal to the ligament of Treitz. The Roux limb is brought through the transverse mesocolon to the right of the middle colic vessels and positioned next to the prepared proximal bile duct.

• Creation of the hepaticojejunostomy (there are multiple techniques)
  • End-to-side anastomosis: Can be used for E1-E3 lesions. In E4 lesions the separated right and left hepatic ducts may be approximated into one “double-barrel” duct, and an end-to-side HJ can be performed. E5 lesions will typically require two separate end-to-side anastomoses of both the aberrant right hepatic duct and the main hepatic duct to the jejunum. The technique begins by placing two corner stitches on the right and left sides incorporating at least 3 mm of duct and mucosa of the jejunum. Blumgart published a technique involving placing sutures on the anterior bile duct wall and placing rubber shods on them to retract and expose the posterior aspect of the anastomosis.[12] Next 4-0 or 5-0 interrupted monofilament absorbable sutures are placed to approximate the posterior wall completely. The anterior wall is then completed utilizing the originally placed sutures in a buried knot fashion.
  • Side-to-side anastomosis: A transverse ductotomy is made in the LHD and may be extended into the RHD at the confluence. The open end of the injured main bile duct is then sutured closed with nonabsorbable suture. A side-to-side anastomosis is then performed starting with the posterior wall in an interrupted or running fashion utilizing a 4-0 or 5-0 monofilament absorbable suture.
  • Stenting of the HJ anastomosis is controversial. There has been weak evidence that it prevents HJ anastomotic leaks or strictures and is selectively used according to surgeon preference. Stenting may be done in several ways. An already present PTC biliary stent can be passed from the proximal bile ducts through the anastomosis into the jejunum. Another technique requires placing a Silastic stent through the anastomosis into the proximal bile ducts and then bring it anteriorly through the hepatic parenchyma. A third option is to place a T tube through the anterior wall of the bile duct and having one limb traversing the HJ anastomosis. The long vertical portion is then brought out through the abdominal wall.
  • The cornerstone of the technique is to achieve a tension-free anastomosis.

• Creation of entero-enterostomy: An end-to-side jejunojejunostomy is created with a single layer continuous hand-sewn technique, allowing for an approximately 40 cm bilio-enteric limb length.

• Intraabdominal drain placement and laparotomy closure

Complications

Perioperative mortality is reported to be 1.7%, and morbidity is 43%.[5]

The most common early complications are bile leak (5%), intraabdominal abscess (3%), wound infections (8%), and cholangitis (6%). Very few of these patients require intervention and if they do, it is by percutaneous means.[13]

Late complications are primarily comprised of anastomotic stricture formation and recurrent cholangitis which with advancing techniques is highly responsive to endoscopic ballooning and stenting.[14]

Clinical Significance

Many major bile duct injuries will require surgical repair. There are many described techniques for complex biliary injury repairs including primary repair or primary end to end anastomosis of bile ducts, choledochoduodenostomy, and cholecystojejunostomy. The most popular surgical repair is the Roux-en-Y hepaticojejunostomy. This operation has been consistently superior to the other methods when considering long-term outcomes. There are many different techniques described to perform an RYHJ, and the operating surgeon should choose the method with which he or she is most comfortable or experienced.

Enhancing Healthcare Team Outcomes

Iatrogenic biliary tract injury is a rare but devastating complication of the commonly performed laparoscopic cholecystectomy in the modern age. The extent of the injury can range from mild to severe, and treatments vary according to the injury. Management of bile duct injuries has 3 main goals: control of sepsis, defining and classifying biliary anatomy/injury, and definitive repair of the injury. The bile duct injury is primarily managed by an interprofessional team that includes a surgeon, radiologist, gastroenterologist, infection disease consultant, and an intensivist. These patients usually require close monitoring in an ICU setting by critical care nurses and pharmacists for appropriate pain control and management of nutrition. Repair of bile duct injury is also associated with significant complications that include an anastomotic leak, abdominal abscess, liver failure, wound infections, and cholangitis. The mortality rates depend on the type of injury and comorbidity but can range as high as 20-40%.[15][16][17](Level V)