This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.

1. Biliary Injuries
During Laparoscopic
Cholecystectomy
Dr.Atul kumar Mishra
M.S (Gen.Surgery)

2. Historical perspective
 First planned cholecystectomy in the world
was performed by Carl Langenbuch in 1882.
 First choledochotomy was performed by
Couvoisser in 1890.
 First iatrogenic bile
duct injury was
described by Sprengel in 1891.
 Prof. Dr. Med Erich Muhe of Boblingen,
Germany, performed the first laparoscopic
cholecystectomy in 1985.

3. Biliary Anatomy
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.

4. Classic anatomy of biliary tree is present in only 30% of individuals,
so it may be said that anomalies are rule, not the exception.
( Maingot‟s abdominal operations)
Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy

5. Anatomy
 Calot's triangle
bounded by cystic duct,
cystic artery, and
common hepatic duct.
 Hepatocystic triangle
bounded by gallbladder
wall and cystic duct, liver
edge, and common
hepatic duct; the cystic
artery (and hence Calot's
triangle) lies within this
space.
(Maingot‟s abdominal operation)

6. Aim of the laparoscopic
cholecystectomy
Surgery (TODAY)->Discharge on same/next day
Complicated / Injury
Long hospital stay
Repeated investigations like USG and
ERCP
Radiologic interventions
Re-operations

7. Laparoscopic
cholecystectomy Pros and
cons
 General advantages
Shorter stay in hospital
Faster recovery period
Reduced post-op recovery time
Less postoperative pain
Improved cosmetic outcome
 Disadvantage
Increase in serious bile duct
and injuries
complications

8. Operating Room Setup
•
•
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

9. Epigastric
region, below
XP
Trocar Placement
Subcostal,
MidClavicular
Mid-A,
between 12th
rib and iliac
crest
Umbilical
region

10. Introduction
 Open cholecystectomy was standard practice
for treatment of symptomatic gall bladder
disease until late 1980‟s.
 At present 90% of cholecystectomies performed
by LC which is one of the commonest surgical
procedure in world.
 Unfortunately, widespread application of LC led
to concurrent rise in incidence of major bile
duct injuries (BDI),which are more complicated
than after open procedures.
 Since its introduction and routine use in 1990s,
the incidence of biliary injuries has doubled
from 0.2% to 0.4% and remained constant
despite advances in knowledge, technique, and
technology.

11. Classic Laparoscopic Injury
Mistaking common bile duct for the cystic duct

12. Thermal Injuries
 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

13. Bile duct injuries during
cholecystectomy
 In 1990s, high rate of biliary injury was due
to learning curve effect.
 Surgeon had 1.7% chance of a bile duct
injury occuring in first case and 0.17% at
the 50th case.
 However most surgeons passed through
learning curve, steady – state reached,
but there has been no significant
improvement in the incidence of biliary
duct injuries.

14. Biliary Injuries during
Cholecystectomy
 Open cholecystectomy has been associated
historically with 0.2% to 0.5% risk of
postoperative Biliary tract injuries.
 On other hand LC has been associated with 2.5fold to 4-fold increase in the incidence of
postoperative BDI compared with OC.

15.  These preventable injuries can be
devastating,
increasing
morbidity,
mortality, and medical cost, while
decreasing the patient‟s quality of life.
 Biliary injuries will always exist, and we
need to be aware of the best methods to
avoid, evaluate, and treat them.

16. Incidence of IBDI following cholecystectomy (%)
Author
IBDI incidence following
OC
IBDI Incidence following
LC
Mc Mohan et al,1995
0.2
0.81
Strassberg et al, 1995
0.07
0.5
Shea et al,1996
0.19-0.29
0.36-0.47
Targarona et al, 1998
0.6
0.95
Lillemoe et al, 2000
0.3
0.4-0.6
Gazzaniga et al, 2001
0.0-0.5
0.07-0.95
Savar et al,2004
0.18
0.21
Moore et al,2004
0.2
0.4
Misra et al,2004
0.1-0.3
0.4-0.6
Gentileschi et al,2004
0.0-0.7
0.1-1.1
Kaman et al,2006
0.3
0.6

17. Risk Factors for Biliary
tract injury
 Surgeon related factors
Lack of experience (learning curve)
Misidentification of biliary anatomy
Intraoperative bleeding
Lack of recognition of anatomical variations of
biliary tree
Improper interpretation of IOC
Improperly functioning equipment

18. Risk for biliary tract injury
 Patient related
Acute and chronic cholecystitis
Empyema
Long standing recurrent disease ->
fibrosis
Porcelain gallbladder
Obesity
Previous surgery
Male sex
Advanced age

19. The Effect of Acute Cholecystitis on
Lap. cholecystectomy complications
 Complication rate three times greater than
for elective LC.
 Early cholecystectomy (72 h) outcome
better than delayed cholecystectomy.
 Conversion rate to open cholecystectomy
is higher than elective cholecystectomy
35% vs 9%.

20. Risk Factors for biliary tract
injuries Anatomic Variations
Present in 18 – 39% cases
Dangerous variations predisposing to BTI are present in only 3-6%
of cases
Abnormal biliary anatomy
Short cystic duct, cystic
duct entering in the right
ductAccessory right
hepatic duct
Arterial anomalies
Right hepatic artery running
parallel to the cystic duct
Anomalous or accessory
right hepatic artery

21. (Sabiston text book of surgery 19thedtn.)

23. 
Summary of Causes of Bile
Duct Injuries
Misidentification of
Common bile duct
Common hepatic duct
An aberrant duct (usually on the right side)
 Technical failure such as
Slippage of clips placed on the cystic duct
Inadvertent thermal injury to CBD
Tenting of CBD during clip placement
Disruption of a bile duct entering directly into gallbladder fossa .
(Goal of dissection should be conclusive identification of cystic structure
within Calot triangle)
(If the cystic duct and cystic artery are conclusively and correctly identified
before dividing, more than 70% of bile duct injuries would be avoided )

24. Technique
 Four methods of identification of cystic
structures during cholecystectomy
1) Routine cholangiography
2) Critical view technique
3) Infundibular technique-> widely used
4) Dissection of main bile duct with visualization of
cystic duct or common duct insertion->
( increased chance of either thermal or
retraction injury to CBD, aberrant insertion of
cystic duct can also complicate this approach)

25. Routine intra-op cholangiogram
(IOC)
Laparoscopic ultrasonography
 Performed routinely or not ?
 Done via presumed cystic duct
 If this happens to be CBD, injury has already
occurred!!
 IOC does not identify all aberrant ducts
 Arterial anatomy not identified
 IOC does not prevent BDI but may reduce its
severity ( if correctly performed & interpreted, IOC
can prevent complete CBD transection)
 IOC  higher rate of intra-op identification of BDI 
decreased cost of treatment & shorter hospital stay

26. 
If critical view not obtained due to inflamation or hostile
anatomy perform IOC prior to dividing cystic duct .
Routine IOC reduces CBD injuries from 0.58% to 0.39%
(American Medicare data base study)

27. Critical view of safety
 Calot‟s triangle dissected
free of all tissue except
cystic duct & artery
 Base of liver bed exposed
 When this view is achieved,
the two structures entering
GB can only be cystic duct
& artery
 Not necessary to see CBD

28.  Infundibular technique, although widely used, is
prone to failure in situations where cystic duct is
hidden because of diffuculty retracting the
gallbladder as a result of severe inflammation or
one or more large stone effacing or fusing the
cystic duct-common duct junction.
 In such situation, area where infundibulum
narrows can be interpreted to be cystic duct
when it is actually the cystic duct and common
duct together.

29. (A)Usual anatomy when infundibular technique applied. Cyst ductgallbladder junction is characterized by a flaring tunnel
shape(boldlines). Arrow represents circumferential dissection of CDgallbladder junction during infundibular technique.
(B) Inflammation can pull CBD on the gallbladder creating similar
flaring tunnel shape. As a result, CBD mistaken for cystic duct,
resulting in classic injuries.
CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and
vasculo-biliary injury in laparoscopic and open cholecystectomy. J
Hepatobiliary Pancreat Surg 2008;15(3):285;)

30. Cystic duct or CBD?
2 – 3mm wide
5mm wide
CD > 5mm – Is it CBD?
Even with low cystic CBD goes behind Duct behind duodenum
duct insertion, CD duodenum
must be CBD
rarely goes behind
duodenum
Double cystic duct
very rare
No vessels on
surface
--
Vessels on
surface
2 ducts seem to go towards
inflammed Gallbladder –
one must be CBD
--

31. Classical LC BDI

32. Strasburg Classification
 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
 Type E Transection involve >50%
Subdivided as per Bismuth
classification into E1 to E5

33. Strasburg Classification,
cont’d
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

34. Class I CBD mistaken for cystic duct, but error recognized before
CBD is divided.
Class II Damage to CHD from clips or cautery placed on duct. Often
occurs where visibility is limited due to inflammation or bleeding.
Class III Most common (60%), CBD mistaken for cystic duct. Common
duct is transected and variable portion that includes junction of cystic
and common duct is excised .
Class IV Damage to right hepatic duct , either because this structure is
mistaken for cystic duct, or injured during dissection.

35. Bile duct injury
 Prevention should be main point
 (much more important than treatment)
 ALL laparoscopic cholecystectomies ARE difficult!
 None of them is easy!
 If injury occurred, …
who should treat it?
when should it be treated?
how should it be treated?

36. Prevention







30 laparoscope, high quality imaging equipment
Firm cephalic traction on fundus & lateral traction on
infundibulum, so cystic duct perpendicular to CBD
Dissect infundibulo-cystic junction
Expose “Critical view of safety” before dividing cystic
duct
Convert to open, if unable to mobilise infundibulum or
bleeding or inflammation in Calot‟s triangle
Routine intra-op cholangiogram
Intraoperative laparoscopic ultrasound (IOUS) .
Mastery of Surgery 6th ed.

37. Changing the Culture of
Cholecystectomy: Stopping Rules
 Safety and avoiding BDI should be paramount
concern to surgeon performing LC.
 LC can be converted to open procedure or even
aborted if local conditions present unacceptable
risks of danger.
 As Strasberg points out, the negative effects of
conversion or even aborting procedure and
placing a cholecystostomy tube are minor
compared with the negative effect of a BDI.
 Failure of progression of dissection, inability to
grasp and retract gallbladder, anatomic ambiguity,
poor visualization of field due to hemorrhage,
should trigger the surgeon to consider alternate
approach.
 Conversion rate < 5% can be expected in hands of

38. Timing of Identification
• Intra-op
• Unexpected ductal structures seen
• Bile leak into field from lacerated or
transected duct
• Post-op
• Depends on continuity of bile duct &
• Presence or absence of bile leak

39. 








Presentation of Bile Duct
Injuries
About 25% recognized intraoperatively.
About 25% discovered within 24 hours post- operative
About 50% present weeks to years post-operative.
Most BDI are not recognized intraoperatively, and patients sent home after
or within 24 hours.
Patients who fails to recover within first few days or develop progressive
vague abdominal symptoms.
Abdominal fullness, distension, nausea, vomiting, abdominal pain, fever and
chills.
Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis, or multi
organ system failure.
Clinical presentationBiliary obstructions-> anorexia, jaundice, liver enzyme elevation
Bile leaks
Both can occur simultaneously
Concomitant vascular injuries (complicate matter)
Obstruction secondary to biliary stricture appear weeks to month later and
may present with recurrent colangitis, obstructive jaundice, or secondary
biliary cirrosis.

40. Intraoperative Detection
 If experienced, convert to Open Procedure and perform
Cholangiography (determine extent of injury)
 If
not
experienced,
perform
cholangiogram
laparoscopically with intent of referring patient
(placement of drains)
 Consult an experienced hepatobiliary surgeon
Quicker the repair, better the outcome!!!
 Acute Management
Biliary catheter for decompression of biliary
tract and control of bile leaks
Percutaneous drainage of intraperitoneal bile

41. Clinical Presentation (post-op)
• Obstruction
• Clip ligation or resection of CBD 
obstructive jaundice, cholangitis
• Bile Leak
• Bile from intra-op drain or
• More commonly, localized biloma or free
bile ascites / peritonitis, if no drain
• Diffuse abdominal pain & persistent ileus
several days post-op  high index of
suspicion  possible unrecognized BDI

42. Post-Operative Detection
Plan
 Controlling sepsis, establish biliary drainage, postulate
diagnosis, type and extent of bile duct injury.
 Broad-spectrum antibiotics
 No need for an urgent laparotomy. Biliary reconstruction
in presence of peritonitis results a statistically worse
outcome.
 No need for urgent with reconstruction of biliary tree.
Inflammation, scar formation and development of fibrosis
take several weeks to subside.
 Reconstruction of biliary tract is best performed
electively after interval of at least 6 to 8 weeks.

43. BDI Management
 Investigation
 Ultrasonagraphy and CT -- Ductal
dilatation intra-abdominal collection and
dilatation of biliary tree.
 Cholangiogram
 ERCP—biliary anatomy and
assess the injury
 PTC—define biliary anatomy
proximal to injury
 MRCP—noninvasive (can miss
minor leaks)
HIDA scan -- If doubt exists, HIDA
scan can confirm leak but not the specific
leak site
 MR angiography—vascular injuries

44. When realise that there is an injury, ASK for HELP!
If possible do not try to repair, even you are experienced
An experienced and FRESH surgeon should repair the
injury.
If it is impossible AND it is a difficult injury that you can not
treat, place catheters Lost‟, primarypatient. (end to end CBD
There is no „Tissue and refer the repair
repair) over T-tube???
stricture rate is high!!!
There is „Tissue Lost‟, biliodigestive anastomosis:
choledocoduodenostomy/ Roux-en-Y
hepaticojejunostomy
Primary repair  high incidence of failure 
percutaneous or endoscopic balloon dilatation
later

45. Preoperative Investigation and
Preparation for the Procedure
■ Communication with previous surgeon
■ Previous surgical report
■ Laboratory tests: bilirubin, alkaline
phosphatase, ALT, AST, albumin, coagulation
parameters, white blood cell count
Principles of Repair
■ Anastomosis should be tension free, with good blood
supply, mucosa to mucosa and of adequate caliber.
Hepaticojejunostomy should be used in preference to either
choledochocholedocotomy or choledochoduodenostomy.
Anterior longitudinal opening in the bile duct with a long sideto-side anastomosis is preferred.
Dissection behind the ducts should be minimized in order to
minimize devascularization of the duct.

46. Timing of Repair
Factors favoring immediate repair are:
(1) Early referral
(2) Lack of right upper quadrant
bile collection
(3) Simple injuries
(4) No vascular injury and
(5) Stable patient
Factors favoring delayed repair are:
(1) Late (less than 1week after injury) referral
(2) Complex injuries (types E4, E5)
(3) Thermal etiology
(4) Concomitant ischemic injury

47. Strasburg classification
Type A
Type B & C
Potentialy serious injuries
More common since
introduction of LC
No reconstruction
Treated
endoscopicaly
Type B
Silen
t
Type D
<25
%
25% - 50% or
 Caused by diathermy or
Repaired primarily Small bile duct
Over T-tube
Type C
Pain or cholangitis
many yrs. after
injury
Biliary fistula
Asymptomatic atrophy
of involved liver
Compensated by
hypertrophy of normally
drained liver
Type E (>50%)
Volume
less
Converted
to
Reconstruction by
hepaticojejunostomy
B,C and E1 to E5 are
major
biliary injuries
Reconstruction
Persistence

48. ERCP – multiple stents
• Lateral duct wall
injury or cystic duct
leak 
transampullary stent
controls leak &
provides definitive
treatment
• Distal CBD must be
intact to augment
internal
drainage with
endoscopic stent

49. Simpler injuries types A and D may be treated in community
setting when discovered intraoperatively by endoscopic or percutaneous
techniques when they present in postoperative period.
More complex injuries that require hepaticojejunostomy for repair
(types B and C injuries and most to type E injuries).
More complex injuries types E1 and E2 may also be treated by
nonsurgical techniques when they present as strictures.
Notations >2 cm and <2 cm in types E1 and E2 indicate length of
common hepatic duct remaining.

50. Bile
leak
Immediate intra operative
diagnosis
injurMinor y
Delayed diagnosis
Major injury
Drainage
Low -output
High-output
Repair over
T-tube
Experienced
No experienced
Observe
hepatobiliary
hepato-Biliary surgeon surgeon available
ERCP
Resolve < 5-7 days Continued
Clip open duct Call second surgeon
Roux-en-Y hepaticoDrain
jejunostomy
Suspected CBD
IV antibiotics
injury
Transfer to tertiary
Cystic duct stump leak PTC to deliniate anatomy
centre
Control drainage
Duct of Luschka
Repair by experienced
Stent± sphincterectomy
hepatobiliary surgeon
Sphinctrectomy

51. Cholangiography (ERCP + PTC)
 Percutaneous
(PTC)
transhepatic
cholangiography
 Defines proximal anatomy
 Allows
placement
of
percutaneous
transhepatic
biliary
catheters
to
decompress biliary tree  treats or
prevents cholangitis & controls bile leak

52. ERCP – clips across CBD
 CBD transection 
normal-sized distal
CBD upto site of
transection
 Percutaneous
transhepatic
cholangiography
(PTC) necessary
 Surgery

53. Intraoperative repair

54. Surgical repair
Choledocho-choledochostomy

55. Surgical repair
Choledocho-duodenostomy

56. Biliary enteric anastomosis
 Most laparoscopic BDI
– complete
discontinuity of biliary
tree
 Surgical
reconstruction, Rouxen-Y
hepaticojejunostomy
 Tension-free, mucosato-mucosa

57. Surgical repair
Hepatico-jejunostomy (Roux-en-Y)

58. Definitive management
 Goal
 Reestablishment of bile flow into proximal
GIT
 In a manner that prevents cholangitis,
sludge or stone formation, restricturing &
progressive liver injury
 Bile duct intact & simply narrowed 
percutaneous or endoscopic dilatation

59. Treatment summary
 Strasberg Type A – ERCP + sphincterotomy +
stent
 Type B & C – Traditional surgical
hepaticojejunostomy
 Type D – Primary repair over an adjacently
placed T-tube (if no evidence of significant
ischemia or cautery damage at site of injury)
 More extensive type D & E injuries – Roux anY hepaticojejunostomy over a 5-F pediatric

60. Summary
• Multidisciplinary management of BDI 
expertise of surgeons, radiologists &
gastroenterologists
• Mismanagement  lifelong disability & chronic
liver disease
• BDI with lap. Chole  results of operative
repair, excellent in Specialist Centres