Injuries to the bile duct are almost universally iatrogenic 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. Laparoscopic cholecystectomy performed for acute cholecystitis and more so for gall bladder empyema or gangrenous cholecystitis, has a higher chance of bile duct injury. Any major bile duct injury may result in significant morbidity, increased mortality, and financial burden on the patient. 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).
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.
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), hepatic resections, or hepatic transplants.
This is the most common system used (Type A to E; E1 to E5)
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. 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.
The procedure recommended for specific injuries requiring operative repair:
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.
Standard laparotomy surgical equipment is required.
Specific for HJ:
If expertise is available, consideration may be given to perform a minimally invasive repair(laparoscopic or robotic).
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.
Perioperative mortality is reported to be 1.7%, and morbidity is 43%.
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.
Late complications are primarily comprised of anastomotic stricture formation and recurrent cholangitis which with advancing techniques is highly responsive to endoscopic ballooning and stenting.
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.
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%.(Level V)
|||Moghul F,Waheed A, Bile Duct Injury 2020 Jan; [PubMed PMID: 31536309]|
|||McPartland KJ,Pomposelli JJ, Iatrogenic biliary injuries: classification, identification, and management. The Surgical clinics of North America. 2008 Dec [PubMed PMID: 18992598]|
|||Kashyap S,Mathew G,Abdul W,King KC, Gallbladder Empyema . 2020 Jan [PubMed PMID: 29083646]|
|||Kowalski A,Kashyap S,Mathew G,Pfeifer C, Clostridial Cholecystitis . 2020 Jan [PubMed PMID: 28846291]|
|||Sicklick JK,Camp MS,Lillemoe KD,Melton GB,Yeo CJ,Campbell KA,Talamini MA,Pitt HA,Coleman J,Sauter PA,Cameron JL, Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Annals of surgery. 2005 May [PubMed PMID: 15849514]|
|||Recio-Boiles A,Kashyap S,Babiker HM, Gallbladder Cancer . 2020 Jan [PubMed PMID: 28723031]|
|||Strasberg SM,Hertl M,Soper NJ, An analysis of the problem of biliary injury during laparoscopic cholecystectomy. Journal of the American College of Surgeons. 1995 Jan [PubMed PMID: 8000648]|
|||Stewart L,Way LW, Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Archives of surgery (Chicago, Ill. : 1960). 1995 Oct [PubMed PMID: 7575127]|
|||Mishra PK,Saluja SS,Nayeem M,Sharma BC,Patil N, Bile Duct Injury-from Injury to Repair: an Analysis of Management and Outcome. The Indian journal of surgery. 2015 Dec [PubMed PMID: 26730060]|
|||Snyder E,Kashyap S,Lopez PP, Hepatobiliary Iminodiacetic Acid Scan . 2020 Jan [PubMed PMID: 30969603]|
|||Myburgh JA, The Hepp-Couinaud approach to strictures of the bile ducts. I. Injuries, choledochal cysts, and pancreatitis. Annals of surgery. 1993 Nov [PubMed PMID: 8239775]|
|||Hirano S,Tanaka E,Tsuchikawa T,Matsumoto J,Shichinohe T,Kato K, Techniques of biliary reconstruction following bile duct resection (with video). Journal of hepato-biliary-pancreatic sciences. 2012 May [PubMed PMID: 22081253]|
|||Pitt HA,Sherman S,Johnson MS,Hollenbeck AN,Lee J,Daum MR,Lillemoe KD,Lehman GA, Improved outcomes of bile duct injuries in the 21st century. Annals of surgery. 2013 Sep [PubMed PMID: 24022441]|
|||Lillemoe KD,Melton GB,Cameron JL,Pitt HA,Campbell KA,Talamini MA,Sauter PA,Coleman J,Yeo CJ, Postoperative bile duct strictures: management and outcome in the 1990s. Annals of surgery. 2000 Sep [PubMed PMID: 10973393]|
|||Otto W,Sierdziński J,Smaga J,Dudek K,Zieniewicz K, Long-term effects and quality of life following definitive bile duct reconstruction. Medicine. 2018 Oct [PubMed PMID: 30313064]|
|||Booij KAC,Coelen RJ,de Reuver PR,Besselink MG,van Delden OM,Rauws EA,Busch OR,van Gulik TM,Gouma DJ, Long-term follow-up and risk factors for strictures after hepaticojejunostomy for bile duct injury: An analysis of surgical and percutaneous treatment in a tertiary center. Surgery. 2018 May [PubMed PMID: 29475612]|
|||Fong ZV,Pitt HA,Strasberg SM,Loehrer AP,Sicklick JK,Talamini MA,Lillemoe KD,Chang DC, Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes. Journal of the American College of Surgeons. 2018 Apr [PubMed PMID: 29307612]|