19. ⦿Strasberg’s Critical view (1995)
◼Concept of thorough dissection
◼and delineation of all the structure in the
hepatocystic triangle
20. ⦿Strasberg’s Critical view (1995)
◼Separate lower GB from liver bed to cystic plate
◼Only 2 structures entering gallbladder
◼Anterior and Posterior views required
21. ⦿Unclear anatomy
⦿Dangerous pathology
⦿Clips are small for the duct
⦿Unusual field of vision
◼More duodenum, less liver
Red Flag signs of BDI
⦿Recognize difficult cholecystectomy, be more
cautious; Get help for difficult cases.
⦿Always feel free to Convert or Consult
24. ⦿Fluorescence cholangiography
◼Indocyanine Green binds to plasma proteins
(primarily albumin) and is taken up by hepatic
parenchymal cells (secreted entirely into bile)
◼ICG absorbs light in the NIFR (806nm) and emits
light at a longer wavelength (830nm)
25. ⦿Safe & effective, faster and easier than IOC
⦿Pitfalls
◼choledocholithiasis, occluded cystic duct
⦿Hurdles to use –
◼Initial investment, Continued equipment cost
26. ⦿ The first classification of bile duct injury,
authored by H. Bismuth in 1982.
⦿ Based on the location of the injury in the biliary
tract from bile duct bifurcation, the involvement
of bile duct bifurcation, and individual right
sectoral duct.
27. ⦿Type A
◼Cystic duct leaks or
◼Leaks from small ducts in liver bed
⦿Type B
◼Occlusion of aberrant right hepatic ducts
⦿Type C
◼Transection of aberrant right hepatic ducts
⦿Type D
◼Partial (<50%) transection of major bile duct
28. ⦿ Type E of the Strasberg classification is an
analogue of the Bismuth classification.
29. ⦿ Allows differentiation between bile leakage from
the cystic duct or aberrant right sectoral branch
and injuries performed during laparoscopic
cholecystectomy.
⦿ Drawback – No information of vascular injury.
35. ⦿Vascular injuries are included in Type C and
Type D .
⦿This classification provides the location of
tangentially or completely transected bile
ducts above or below the bifurcation of the
hepatic duct.
⦿Also, describes associated vascular injuries.
36. ⦿Be calm
⦿Don’t panic
⦿Shouting on assistants will not solve the
situation
⦿One minute rule
⦿Assess complexity
⦿Assess your experience
⦿Call for help (colleague assistance)
38. ⦿Aberrant right sectoral hepatic duct
◼suture
◼Drain + delay repair
⦿Small / simple laceration
◼Consider repair with 4-0 absorbable suture
(extensive dissection increases stricture rate)
⦿Non circumferential laceration
◼Repair over T tube.
39. ⦿Complete transsection
⦿End to end repair over T tube, 4-0 absorbable
suture
◼Risk of stricture
⦿Roux-en-Y Hepaticojejunostomy
◼preferred
40. ⦿Place catheter in proximal duct
⦿Place drains
⦿Avoid laparotomy just for drain
⦿Refer to tertiary care centre
◼(experienced surgeon)
⦿GOAL:
◼Drain / control of sepsis
◼Maintain CBD length
41. ⦿Do not worsen an already bad situation
⦿If a BDI occurred make sure you avoid a
second mistake
⦿This is not the time to do your once a year
hep-jej
⦿Experienced surgeon:
◼94 Vs 17% success rate
⦿Success of repair is inversely proportional to
the number of operative attempts
42. ⦿Bile leak
◼Pain, bile in drain, signs of peritonism
⦿Biliary obstruction
◼Abnormal LFT, Jaundice, cholangitis
43. ⦿US/CT abdomen
◼To look for any collection/Guided drainage
⦿HIDA scan
◼Confirms leak but fail to give anatomic detail we
need
44. ⦿PTC
◼To visualize the proximal ducts and assess the
grade of injury
⦿MRCP
◼Non-invasive test of choice to assess the grade of
injury
◼Both proximal and distal ducts can be seen and
leaks also can be identified
49. ⦿The desired pre-requisites are as with any
anastomosis
⦿Well vascularised ducts
⦿Repair without tension
⦿Largest possible diameter
⦿Mucosa to mucosa apposition
⦿Single layer repair
⦿Absorbable monofilament suture
50.
51. ⦿Surgeon’s factors
⦿Failure to inform the patient of the risks
involved in the procedure.
⦿Poor documentation
◼Not documented, not done
⦿Poor safety procedures
⦿Lack of transparency
◼If there is complication, be transparent and
truthful and get a specialist involved early.
⦿Delay in diagnosis
52. ⦿Good documentation can save you
⦿A detailed consent form including all possible
risks associated with procedure discussed
thoroughly with patient and family,
◼can prevent/reduce the risk of a medico-legal suit
being filed, and even if filed, being decided in the
patient’s favor
⦿Make sure, you have good insurance
⦿Find a legal team you trust.
⦿Do not research the patient’s chart or talk
with others about the case unless directed to
do so
