O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.
BILE DUCT INJURIES
Dr. Joe M Das
Junior Resident
S3 Unit
• Bile duct injuries represent a complex clinical
scenario seen with increased frequency
owing to
– aberrant anatomy and
–...
HISTORY
• Earliest known gall stones - Priestess of
Arnan (1085-945 BC) - Egyptian
• Recognition of gallstones was first
recorded ...
• Observations of human gallstones were first
demonstrated during autopsy by Gentile da
Foligno (1341) in Padua
• In 1667,...
• John Stough Bobbs first elective
cholecystostomy in
Indianapolis for
hydrops of the
gallbladder
• In 1878 Kocher
drained...
• Ludwig Georg
Courvoisier (18431918).
– Law (Statistical
article on the
pathology and
surgery of the biliary
system)
– Fi...
First open
cholecystectomy
•Dr Carl Johann
August
Langenbuch
(German
surgeon)
•July 15, 1882, at
Lazarus
Krankenhaus in
Be...
• Bernard Naunyn
(1839-1925) pathophysiological
basis of gall stone
formation
• Hans Kehr inventing a T tube
First laparoscopic
cholecystectomy
• Erich Mühe in
Germany in 1985
• The first laparoscopic cholecystectomy in India
was done in 1990 at the J.J. Hospital, Mumbai
"The pleasure of a physician is little,
the gratitude of patients is rare and
even rarer is material reward, but,
these th...
REVIEW ON SURGICAL
ANATOMY
Extra hepatic biliary tract
• Left hepatic duct – segment 2,3,4.
• Right hepatic duct
Right anterior: 5,8
Right posterior:...
• Common bile duct :
– Length : 5 to 9cm
– Diameter : 6 to 8 mm
– Supraduodenal , retroduodenal &
intrapancreatic .

• Gal...
• Cystic duct :
– Length : 1 to 5 cm
– Diameter : 3 to 7 mm

• Blood supply :
– Distal : Gastroduodenal,retroduodenal,
pan...
Common bile duct
Calot’s triangle
(Hepatobiliary / Cystohepatic triangle)
• Common hepatic duct ,liver and cystic duct.
• Cystic artery, RH...
Duct of Luschka (Accessory hepatic /
cholecystohepatic duct)
Variations of Accessory duct at Porta
Hepatis
Anatomical variations of Gall bladder
• Agenesis of GB : 0.02%.

• Cholangiography
Multiple Gall Bladder
• 1 in 3800.
• Should be removed
even when normal.
• Magnetic or CT
cholangiography
Ectopic Gall Bladder
• Normally formed gall bladder in an
abnormal site.
• Intrahepatic , left sided , transverse or
retro...
Intrahepatic & floating
Cystic duct Anomalies
• Only 33% have classical anatomic position and
course.
• Most important : junction of cystic duct w...
(a)Low & parallel course (15%)
(b)Adherent to CHD (6%)
(c)Normal course of the cystic duct(60)
(d)Short & absent cystic duct(3.5&0.5)
(e)Anterior spiral course to left of CHD(2)
(f)Posterior spiral course to left of CHD(13)
Variations of CBD & Extra hepatic
confluence.
• Convergence of hepatic ducts vary greatly.
• Sectoral ducts: nonconfluence...
(a) 1.4% (b) 2.6%
(c) 0.16% (d)0.08%
(e) 10.7% (f) 85%
Cystic dilatations of biliary tree
Todani Classification
• Ty 1- Solitary fusiform extrahepatic cyst.
• Ty 2 – Extrahepatic supraduodenal diverticulum.
• Ty 3 – Choledochocele - i...
Cystic artery variations
• 20% cases arise from middle & left hepatic
artery.
• Replacements : gastroduodenal ,celiac axis...
Diagram shows cystic artery classification based on the relationship of the cystic artery to
the Calot triangle.

Sugita R...
Causes of bile duct injury
CYSTIC DUCT INJURIES AND BILE LEAK
• Cystic duct : 50%
• Subvesical or Gallbladder bed : 25%
• Major bile duct :25%
• Cystic duct leak
– failure to safely ligate the cystic duct
– failed application of endoscopic clips.

• Acute cholecyst...
Clinical features and investigation
• Excessive right upper quadrant pain and
elevated bilirubin.
• Ultrasound or CT
• HID...
Extra hepatic bile duct injuries
• Common hepatic duct most commonly
injured.
• During dissection of Calot’s triangle &
in...
Intrahepatic bile duct injuries
• During dissection of gallbladder off the liver
bed.
• Right hepatic duct more commonly i...
Cause of biliary strictures
•
•
•
•
•

Direct injury
Clipping of duct
Thermal injury
Ischaemia
Inflammation and scarring s...
Mechanisms of injury and risk factors
• Anatomic variations.
• Complicated pathology.
• Technical error.

• Thermal and la...
Complicated pathology
• Acute inflammation and scarring of the
triangle of calot.
• Acute cholecystitis.
• Acute pancreati...
Technical errors
• Cephalad and lateral retraction of gall bladder
is necessary to expose the structures.
• Cautious retra...
• Avoid strenous dissection too close to
the CBD.
• Blind application of clips to achieve
hemostasis.
• Willingness to con...
Thermal and laser injuries
• Use of electrocautery
• Avoided near the CBD

• Bipolar cautery is better.
• Laser : severe i...
CLASSIFICATION
Bergmann classification of bile duct
injuries
Stewart Way classification of
Laparoscopic bile duct injuries
A drawback of the
Bismuth
classification is that
patients with limited
strictures, isolated
right hepatic duct
strictures,...
Strasberg
classification is able
to classify all types
of injury and is used
extensively in
describing bile duct
injuries ...
• McMahon
• Amsterdam Academic Medical Center's
classification (1996)
• Neuhaus' classification (2000)
• Csendes' classifi...
What are the clinical features and how
to detect these injuries?
• Most class I injuries are recognized
intraoperatively (about 60–70%).
• Those unrecognised present with mild
abdominal p...
• The majority of class II injuries (60–70%) present
with
– Obstructive jaundice, pruritus, cholangitis, ↑
bilirubin and a...
• CT and USS –
– dilated bile ducts in patients without biliary
fistulas
– non-dilated ducts and abdominal fluid
collectio...
• Patients with class III injuries present like class
I injuries, only they can have a more toxic
illness.
• About 25% of ...
• Laboratory abnormalities are highly
variable
• Total bilirubin can be normal or
elevated (average of 4–5 mg/dl)
• Alkali...
• CT and ultrasound scans - an abdominal
fluid collection and nondilated bile ducts.
• ERCP distinguishes class III from o...
• Class IV injury patients present with abdominal
pain, abdominal distention, ileus, cholangitis,
hepatic abscess (20–25%)...
Routine intraoperative
cholangiography
• Fletcher et al. in 1999 found that
intraoperative cholangiography had a
protectiv...
Is it possible to detect these
injuries intra operatively?
Intraoperative clues to a bile duct injury
• Cholangiogram abnormalities:
– Failure to opacify the proximal hepatic ducts
...
• Atypical features of cystic duct:
– A ‘cystic duct’ that is not completely
encompassed by the standard M/L. clip, which
...
• Anomalous anatomy:
– Second cystic duct, aberrant duct, accessory duct, or
suspected duct of Lushka, these are generally...
How to prevent?
• Proper selection of cases
• In obese patients place the optical port little
higher up from the umbilicus to avoid the
ta...
• While dissecting the Calot’s triangle stay close
to the GB.
• It is advised that Calot’s triangle is dissected in
such a...
• The technique of
“critical view of
safety” of Strasberg
• Calot’s triangle is
completely unfolded
by mobilizing the
gall...
• Always dissect to the right of the line joining the
right free margin of lesser omentum to cystic
node.
• Vessels pulsat...
• Once the Calot’s triangle is fully dissected and
cystic artery has been clipped and cut, GB is
left attached medially to...
• The cystic duct and the
GB neck and
infundibulum together
looks like Lord
Ganesha’s trunk and
head (or elephant’s
trunk ...
• Use the suction-irrigation cannula to aid
in dissection. The oozing surface absorbs
light with a resultant darker pictur...
In case of excessive bleeding during the surgery:

• Have a low threshold for conversion.
• If there is continuous ooze fr...
“I would like to see the day when
somebody would be appointed
surgeon somewhere who had no
hands, for the operative part i...
MANAGEMENT
HOW ESSENTIAL IS TO TREAT BILE
DUCT INJURIES?
• Most bile duct injuries or strictures occur as a
result of cholecystectomy for symptomatic
gallstone disease.
• The majo...
• Biliary strictures may result in significant
morbidity and mortality secondary to
complications such as biliary cirrhosi...
WHAT ARE THE FACTORS ONE SHOULD
CONSIDER BEFORE TREATING BILE DUCT
INJURIES?
1.Timing of diagnosis -

Intra-operative

-

Early post-op

-

Late post-op

2.Extent and level of injury
3.Patient presen...
WHAT ARE THE TREATMENT OPTIONS
AVAILABLE ?
• A multidisciplinary approach
• The team consisting of experienced
interventional radiologists, endoscopists, and
surgeon...
1) Surgical Management
2) Interventional Radiologic Techniques
3) Endoscopic Techniques
• Most of these injuries and stric...
"Surgery is the first and the highest
division of the healing art, pure in
itself, perpetual in its applicability, a
worki...
PRE-OPERATIVE MANAGEMENT
• Early post-op period
 Sepsis /SIRS
 Treat with –Broad spectrum antibiotics
-Percutaneous biliary drainage
- Percutaneo...
• Next step- Pre-op cholangiography (to define
anatomy)
Control bile leak with percutaneous stents
Delayed surgical repair
• Late post-op period
Strictures
Cholangitis
Treat with- Broad spectrum antibiotics

Urgent cholangiography
Biliary dec...
• If patient presents only with jaundice & no
cholangitis
ERC / PTC -

to define anatomy

In these cases biliary decompres...
INTRA OPERATIVE MANAGEMENT
• Intra-operatively, any suspicious biliary injury
1) Intra-op cholangiography
+/Careful dissection
2) Lap to open convers...
• Injury involves <50% of the circumference of
the bile duct wall

Primary closure over a T-tube
• More extensive biliary injury
• Significant thermal damage owing to cauterybased trauma
• Injury involving >50% of the c...
MANAGEMENT OF HEPATIC DUCT INJURIES
• Major bile duct injuries, including transections of
the common common hepatic duct, can be
repaired.
• Isolated hepatic ...
TECHNICAL ASPECTS OF SURGICAL REPAIR
SURGICAL REPAIR
• The blood supply of the common duct is axial
running at 3:00 and 9:00 on the duct.
• These vessels are s...
• The choice and technique of repair
correlates with the success rate.
• End-to-end anastomosisThe common duct (or common ...
Unsuccessful :
1.When repaired at the initial open
cholecystectomy
2. Class III injuries, especially laparoscopic.
• The r...
Roux-en-Y hepaticojejunostomy
• Has the best success
rate for the repair of
a transection injury of
CBD/CHD
Certain technical factors for a successful
hepaticojejunostomy are
• Preoperative eradication of intra-abdominal
infection...
Stenting
• Stenting is useful, however, when very small
ducts are repaired (class IV injuries or class III
injuries where ...
WHEN DETECTED POST-OP….?
• The management of postoperative
biliary strictures following ductal
injury depends on the degree of
injury, the presence...
• After recognition of a bile duct injury or
stricture, a multidisciplinary team consisting of
experienced interventional ...
OVERVIEW
Suspected CBD injury during lap-cholecystectomy
Intra-op cholangiogram
Partial injury(<30%)
Extensive injury(>30%)

Primar...
Role of Interventional Radiology
• Interventional
radiologic techniques
are useful in patients
with bile duct injuries,
leaks, or postoperative
strictures.
• These techniques allow
1)Percutaneous drainage of abdominal fluid
collections
2)Preoperative identification of the ducta...
• Percutaneous transhepatic biliary
dilatation:
– Intrahepatic ductal disease
– ERCP is not possible
– Adjunct to operativ...
ROLE OF ENDOSCOPIC DILATATION IN
BILIARY STRICTURES
• Adjunctive option in patents with a
dominant extrahepatic stricture causing
clinical symptoms.
• Requires multiple sessi...
• Metalic stents are more durable than
plastic stents
• Endoscopic dilation also has a low
mortality rate, but it has a si...
• Complications following endoscopic
biliary interventions:
– Hemobilia
– Bile leak
– Pancreatitis
– Cholangitis
– Re-stri...
POST-REPAIR COMPLICATIONS
1.
2.
3.
4.
5.
6.
7.
8.

Cholangitis
Pancreatitis
Stent occlusion
Stent migration
Ductal perforation
Restricturing
Biliary...
MANAGEMENT OF BILIARY FISTULA
• To define biliary fistula –
‘ a bilirubin rich drainage lasting for more
than 5 days’

• Most of them resolve spontaneou...
3 Rs

• Resuscitation
• Restitution
• Rehabilitation
Resuscitation
 The first stage in the management is the
restoration of volume using crystalloid and
colloid products as a...
• Control of sepsis
• Per cutaneous drainage
• Antibiotcs should only be given for defined
infections and for a set durati...
Non-operative management
• Usually for low output fistula
• Percutaneous drainage
• Trans-hepatic stenting
Surgical intervention
• For early high output fistula
• Persistent sepsis

Reoperation
References
•
•
•
•

Surg Clin N Am 90 (2010) 787-802
Surg Clin N Am 88 (2008) 1329-1343
Schwartz's Principles of Surgery, ...
THANK YOU
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Bile duct injuries
Próximos SlideShares
Carregando em…5
×

Bile duct injuries

Bile duct injuries

  • Seja o primeiro a comentar

Bile duct injuries

  1. 1. BILE DUCT INJURIES Dr. Joe M Das Junior Resident S3 Unit
  2. 2. • Bile duct injuries represent a complex clinical scenario seen with increased frequency owing to – aberrant anatomy and – more lap cholecystectomies being performed • Incidence : – 0.1-0.2 % in open cholecystectomy – 0.4-0.6 % in lap cholecystectomy
  3. 3. HISTORY
  4. 4. • Earliest known gall stones - Priestess of Arnan (1085-945 BC) - Egyptian • Recognition of gallstones was first recorded by a Greek physician Alexander Trallianus (525-605 BC) • The first clinical description of gallstone disease - Gordon Taylor, in his description of the symptoms manifested by Alexander the Great in 323 BC
  5. 5. • Observations of human gallstones were first demonstrated during autopsy by Gentile da Foligno (1341) in Padua • In 1667, Michael Entmuller said, “There are no medicine which will cure gallstones”. • Jean Lovis Petit (1674-1750) – – identifying the biliary colic and other signs of this disease – removing the gallstones after puncturing the gall bladder with trocar and cannula in 1743.
  6. 6. • John Stough Bobbs first elective cholecystostomy in Indianapolis for hydrops of the gallbladder • In 1878 Kocher drained an empyema of gallbladder.
  7. 7. • Ludwig Georg Courvoisier (18431918). – Law (Statistical article on the pathology and surgery of the biliary system) – First choledocholithotomy – Butterflies
  8. 8. First open cholecystectomy •Dr Carl Johann August Langenbuch (German surgeon) •July 15, 1882, at Lazarus Krankenhaus in Berlin
  9. 9. • Bernard Naunyn (1839-1925) pathophysiological basis of gall stone formation • Hans Kehr inventing a T tube
  10. 10. First laparoscopic cholecystectomy • Erich Mühe in Germany in 1985
  11. 11. • The first laparoscopic cholecystectomy in India was done in 1990 at the J.J. Hospital, Mumbai
  12. 12. "The pleasure of a physician is little, the gratitude of patients is rare and even rarer is material reward, but, these things never deter the student who feels the call within him” –BILLROTH
  13. 13. REVIEW ON SURGICAL ANATOMY
  14. 14. Extra hepatic biliary tract • Left hepatic duct – segment 2,3,4. • Right hepatic duct Right anterior: 5,8 Right posterior:6,7 • Hilar plate : seperates biliary confluence from posterior aspect of caudate lobe. • Common hepatic duct lies anterolateral to hepatic artery and vein in the hepatoduodenal ligament.
  15. 15. • Common bile duct : – Length : 5 to 9cm – Diameter : 6 to 8 mm – Supraduodenal , retroduodenal & intrapancreatic . • Gall bladder : – 7 to 10 cm length. – 30 to 60 ml capacity. – Fundus ,body infundibulum and neck
  16. 16. • Cystic duct : – Length : 1 to 5 cm – Diameter : 3 to 7 mm • Blood supply : – Distal : Gastroduodenal,retroduodenal, pancreatoduodenal arteries – Proximal : Right hepatic and cystic arteries. Arteries run parallel to each other at 3 & 9 o’clock position.
  17. 17. Common bile duct
  18. 18. Calot’s triangle (Hepatobiliary / Cystohepatic triangle) • Common hepatic duct ,liver and cystic duct. • Cystic artery, RHA & lymph node.
  19. 19. Duct of Luschka (Accessory hepatic / cholecystohepatic duct)
  20. 20. Variations of Accessory duct at Porta Hepatis
  21. 21. Anatomical variations of Gall bladder • Agenesis of GB : 0.02%. • Cholangiography
  22. 22. Multiple Gall Bladder • 1 in 3800. • Should be removed even when normal. • Magnetic or CT cholangiography
  23. 23. Ectopic Gall Bladder • Normally formed gall bladder in an abnormal site. • Intrahepatic , left sided , transverse or retrodisplaced. • Floating gall bladder : suspended via a mesenteriole.
  24. 24. Intrahepatic & floating
  25. 25. Cystic duct Anomalies • Only 33% have classical anatomic position and course. • Most important : junction of cystic duct with CHD • Length varies : 20% < 2cm ,majority 2-4cm. • Careful dissection of the Calot’s triangle.
  26. 26. (a)Low & parallel course (15%) (b)Adherent to CHD (6%)
  27. 27. (c)Normal course of the cystic duct(60) (d)Short & absent cystic duct(3.5&0.5)
  28. 28. (e)Anterior spiral course to left of CHD(2) (f)Posterior spiral course to left of CHD(13)
  29. 29. Variations of CBD & Extra hepatic confluence. • Convergence of hepatic ducts vary greatly. • Sectoral ducts: nonconfluence of the ducts with independent ending for each duct in duodenum. • Length of CBD varies from person to person.
  30. 30. (a) 1.4% (b) 2.6%
  31. 31. (c) 0.16% (d)0.08%
  32. 32. (e) 10.7% (f) 85%
  33. 33. Cystic dilatations of biliary tree Todani Classification
  34. 34. • Ty 1- Solitary fusiform extrahepatic cyst. • Ty 2 – Extrahepatic supraduodenal diverticulum. • Ty 3 – Choledochocele - intraduodenal diverticulum • Ty 4a – Fusiform intra & extrahepatic cysts. • Ty 4b – Multiple extrahepatic cysts. • Ty 5 – Caroli’s disease (multiple intrahepatic cysts)
  35. 35. Cystic artery variations • 20% cases arise from middle & left hepatic artery. • Replacements : gastroduodenal ,celiac axis or independently from aorta. • Abberant RHA from SMA . • Double cystic artery.
  36. 36. Diagram shows cystic artery classification based on the relationship of the cystic artery to the Calot triangle. Sugita R et al. Radiology 2008;248:124-131 ©2008 by Radiological Society of North America
  37. 37. Causes of bile duct injury
  38. 38. CYSTIC DUCT INJURIES AND BILE LEAK • Cystic duct : 50% • Subvesical or Gallbladder bed : 25% • Major bile duct :25%
  39. 39. • Cystic duct leak – failure to safely ligate the cystic duct – failed application of endoscopic clips. • Acute cholecystitis : wide and friable cystic duct. • Intraoperative cholangiogram • Endo-loop application is better.
  40. 40. Clinical features and investigation • Excessive right upper quadrant pain and elevated bilirubin. • Ultrasound or CT • HIDA (hepatobiliary iminodiacetic acid) • ERCP : procedure of choice
  41. 41. Extra hepatic bile duct injuries • Common hepatic duct most commonly injured. • During dissection of Calot’s triangle & inadequate identification of the structures. • Either partial lacerations or complete transections.
  42. 42. Intrahepatic bile duct injuries • During dissection of gallbladder off the liver bed. • Right hepatic duct more commonly injured than left. • Inadequate / incomplete cholangiogram : convert to open.
  43. 43. Cause of biliary strictures • • • • • Direct injury Clipping of duct Thermal injury Ischaemia Inflammation and scarring secondary to bile leakage.
  44. 44. Mechanisms of injury and risk factors • Anatomic variations. • Complicated pathology. • Technical error. • Thermal and laser injuries.
  45. 45. Complicated pathology • Acute inflammation and scarring of the triangle of calot. • Acute cholecystitis. • Acute pancreatitis. • Chronic cholecystitis. • Mirizzi syndrome • Perforated duodenal ulcer.
  46. 46. Technical errors • Cephalad and lateral retraction of gall bladder is necessary to expose the structures. • Cautious retraction in case of acute inflammation or gangrenous gall bladder. • Avoid application of clips too close to the cystic duct CBD junction.
  47. 47. • Avoid strenous dissection too close to the CBD. • Blind application of clips to achieve hemostasis. • Willingness to convert to open technique. • Early in the surgeons learning curve.
  48. 48. Thermal and laser injuries • Use of electrocautery • Avoided near the CBD • Bipolar cautery is better. • Laser : severe injuries with tissue loss. • Avoid usage near metallic clips • Low intensity for short duration
  49. 49. CLASSIFICATION
  50. 50. Bergmann classification of bile duct injuries
  51. 51. Stewart Way classification of Laparoscopic bile duct injuries
  52. 52. A drawback of the Bismuth classification is that patients with limited strictures, isolated right hepatic duct strictures, or cystic duct leaks cannot be classified
  53. 53. Strasberg classification is able to classify all types of injury and is used extensively in describing bile duct injuries associated with laparoscopic cholecystectomy
  54. 54. • McMahon • Amsterdam Academic Medical Center's classification (1996) • Neuhaus' classification (2000) • Csendes' classification (2001) • CUHK (Chinese University of Hong Kong), 2007
  55. 55. What are the clinical features and how to detect these injuries?
  56. 56. • Most class I injuries are recognized intraoperatively (about 60–70%). • Those unrecognised present with mild abdominal pain, abdominal distention, ileus, with mild elevations in ALP (average 250 U/l) and bilirubin (average 2.3 mg/dl) • Ultrasound and CT scans demonstrate an abdominal fluid collection without dilated bile ducts • ERCP reveals an intact biliary tree with a fistula
  57. 57. • The majority of class II injuries (60–70%) present with – Obstructive jaundice, pruritus, cholangitis, ↑ bilirubin and alkaline phosphatase levels. • The remainder of the patients, who have associated biliary fistulas, present similar to class I injuries. • Some patients may have a prolonged bile leak from surgically placed drain that then closes, with the subsequent development of a biliary stricture and jaundice
  58. 58. • CT and USS – – dilated bile ducts in patients without biliary fistulas – non-dilated ducts and abdominal fluid collections in patients with associated biliary fistulas. • ERCP shows the lesion, invariably with multiple clips overlying it with or without a fistula.
  59. 59. • Patients with class III injuries present like class I injuries, only they can have a more toxic illness. • About 25% of these injuries are recognized during the index operation when bile is seen to drain from the common (or hepatic) duct. • The remainder of patients present later with abdominal pain, abdominal distention, ileus, and cholangitis
  60. 60. • Laboratory abnormalities are highly variable • Total bilirubin can be normal or elevated (average of 4–5 mg/dl) • Alkaline phosphatase can be normal to elevated (average of 225 U/l) • White blood cell count similarly can be normal to mildly elevated (average 13 000/cm2)
  61. 61. • CT and ultrasound scans - an abdominal fluid collection and nondilated bile ducts. • ERCP distinguishes class III from other bile duct injuries involving a biliary fistula. • The findings in class III injuries consist of a truncated common bile duct that is occluded with a clip, and non-filling of the biliary radicles . • PTC demonstrates the proximal extent of these injuries.
  62. 62. • Class IV injury patients present with abdominal pain, abdominal distention, ileus, cholangitis, hepatic abscess (20–25%) • Unlike the other injuries, many (45%) of these patients can have associated severe hemorrhage requiring blood transfusions. • CT and USS – non-dilated ducts and fluid collections • ERCP - injury to or occlusion of the right hepatic duct (or a right sectoral duct) by a clip • PTC - a fistula from the right hepatic ductal system
  63. 63. Routine intraoperative cholangiography • Fletcher et al. in 1999 found that intraoperative cholangiography had a protective effect for complications of cholecystectomy in a retrospective study of 19,000 cholecystectomies.
  64. 64. Is it possible to detect these injuries intra operatively?
  65. 65. Intraoperative clues to a bile duct injury • Cholangiogram abnormalities: – Failure to opacify the proximal hepatic ducts – Narrowing of the CBD at the site of cholangiogram catheter insertion • Bile drainage: – Drainage of bile from any location other than a lacerated gallbladder – Bile draining from a tubular structure
  66. 66. • Atypical features of cystic duct: – A ‘cystic duct’ that is not completely encompassed by the standard M/L. clip, which measures 9mm in the closed position, the structure may be the common duct – A ‘cystic duct’ that can be traced without interruption behind the duodenum, that will prove to be the common duct, not the cystic duct
  67. 67. • Anomalous anatomy: – Second cystic duct, aberrant duct, accessory duct, or suspected duct of Lushka, these are generally the common duct or a hepatic duct – Second cystic artery, this may be the right hepatic artery – Lymphatics surrounding the ‘cystic duct’ or more tissue around the cystic duct than is usually encountered, this indicates that the dissection is in the porta – Fibrous tissue in the gallbladder bed, indicates transection of the proximal hepatic ducts
  68. 68. How to prevent?
  69. 69. • Proper selection of cases • In obese patients place the optical port little higher up from the umbilicus to avoid the tangential view of the Calot’s triangle. • Posterior peritoneal fold should be opened before approaching the Calot’s triangle anteriorly. This provides an extra mobility to GB and helps the CHD to fall away from the CD thereby avoiding proximal BDI during the dissection of Calot’s triangle. • Always dissect to the right of the line joining the right free margin of lesser omentum to cystic node.
  70. 70. • While dissecting the Calot’s triangle stay close to the GB. • It is advised that Calot’s triangle is dissected in such a way that the retro-infundibular window is opened first and then the window between the cystic artery and duct is opened. Visualisation of the double window is called “Critical view of Strasberg”.
  71. 71. • The technique of “critical view of safety” of Strasberg • Calot’s triangle is completely unfolded by mobilizing the gallbladder neck from the gallbladder bed of the liver before transecting the cystic artery and duct
  72. 72. • Always dissect to the right of the line joining the right free margin of lesser omentum to cystic node. • Vessels pulsating before clipping should be considered as hepatic artery until proved otherwise. • While dissecting GB from the liver bed stay close to the GB and avoid any injury to superficial portal radical or abnormally superficial right anterior sectoral duct. • Intra-operative cholangiogram may be used routinely in order to better identify the anatomy after dissection of Calot’s triangle.
  73. 73. • Once the Calot’s triangle is fully dissected and cystic artery has been clipped and cut, GB is left attached medially to only one structure, CD. • If the plane between the liver and GB is absent, it might be better to leave a part of posterior GB wall adhered to the liver bed and cauterise its mucosa than to cause an inadvertent injury to hepatic parenchyma resulting in bleeds and postoperative biliary fistula.
  74. 74. • The cystic duct and the GB neck and infundibulum together looks like Lord Ganesha’s trunk and head (or elephant’s trunk and head) respectively and so also called as Lord Ganesha’s sign.
  75. 75. • Use the suction-irrigation cannula to aid in dissection. The oozing surface absorbs light with a resultant darker picture. • In case of impacted stone in the neck, it may be safer to transect the Hartman’s pouch and remove the stone. The left out mucosa can be cauterised and stump is sutured. • In case of a dilated CD where clip cannot adequately close its lumen, it is advised to use endoloop or intracorporeal suturing for safe closure of the stump.
  76. 76. In case of excessive bleeding during the surgery: • Have a low threshold for conversion. • If there is continuous ooze from the inflammed surface, liberal irrigation and aspiration should be used. • If there is sudden arterial spurt, compress the area temporary with small gauge or atraumatic grasper. Irrigate / aspirate and clean the operative field. Effectively control the bleeding vessel with left hand grasper, identify the vessel and arrest bleeding with clips or bipolar electrocautery.
  77. 77. “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work” -Letter to Dr Henry Christian Nov 20, 1911
  78. 78. MANAGEMENT
  79. 79. HOW ESSENTIAL IS TO TREAT BILE DUCT INJURIES?
  80. 80. • Most bile duct injuries or strictures occur as a result of cholecystectomy for symptomatic gallstone disease. • The majority of these patients are young (40– 50 years), female, have a long life expectancy, and are in the most productive years of their life.
  81. 81. • Biliary strictures may result in significant morbidity and mortality secondary to complications such as biliary cirrhosis , cholangitis,portal hypertension. • Because of this, it is essential that these patients have prompt recognition of their problem and a reliable treatment with a longterm success rate.
  82. 82. WHAT ARE THE FACTORS ONE SHOULD CONSIDER BEFORE TREATING BILE DUCT INJURIES?
  83. 83. 1.Timing of diagnosis - Intra-operative - Early post-op - Late post-op 2.Extent and level of injury 3.Patient presentation 4.Hospital setup
  84. 84. WHAT ARE THE TREATMENT OPTIONS AVAILABLE ?
  85. 85. • A multidisciplinary approach • The team consisting of experienced interventional radiologists, endoscopists, and surgeons, coordinated by an experienced hepatobiliary surgeon
  86. 86. 1) Surgical Management 2) Interventional Radiologic Techniques 3) Endoscopic Techniques • Most of these injuries and strictures are best repaired surgically. SURGERY - GOLD STANDARD
  87. 87. "Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth" - Sushruta (400 B.C.)
  88. 88. PRE-OPERATIVE MANAGEMENT
  89. 89. • Early post-op period  Sepsis /SIRS  Treat with –Broad spectrum antibiotics -Percutaneous biliary drainage - Percutaneous/operative drainage of bilomas No hurry for surgical repair - friable tissue -retraction of small ducts
  90. 90. • Next step- Pre-op cholangiography (to define anatomy) Control bile leak with percutaneous stents Delayed surgical repair
  91. 91. • Late post-op period Strictures Cholangitis Treat with- Broad spectrum antibiotics Urgent cholangiography Biliary decompression -Transhepatic biliary drainage -Endoscopic drainage + stent Surgical repair
  92. 92. • If patient presents only with jaundice & no cholangitis ERC / PTC - to define anatomy In these cases biliary decompression has not been demonstrated to improve outcome Surgical repair
  93. 93. INTRA OPERATIVE MANAGEMENT
  94. 94. • Intra-operatively, any suspicious biliary injury 1) Intra-op cholangiography +/Careful dissection 2) Lap to open conversion is often necessary • Isolated, small, non–cautery-based partial lateral bile duct injury Placement of a T tube
  95. 95. • Injury involves <50% of the circumference of the bile duct wall Primary closure over a T-tube
  96. 96. • More extensive biliary injury • Significant thermal damage owing to cauterybased trauma • Injury involving >50% of the circumference of the bile duct wall End-to-side choledochojejunostomy with a Roux-en-Y loop of jejunum should be performed
  97. 97. MANAGEMENT OF HEPATIC DUCT INJURIES
  98. 98. • Major bile duct injuries, including transections of the common common hepatic duct, can be repaired. • Isolated hepatic ducts smaller than 3 mm or those draining a single hepatic segment can be safely ligated. • Ducts larger than 3 mm are more likely to drain several segments or an entire lobe and need to be reimplanted.
  99. 99. TECHNICAL ASPECTS OF SURGICAL REPAIR
  100. 100. SURGICAL REPAIR • The blood supply of the common duct is axial running at 3:00 and 9:00 on the duct. • These vessels are small and easily damaged during extensive mobilization of the duct. • In addition, the majority of the blood supply (60%) comes from below, while only 38% comes from above, further contributing to ischemia in the proximal portion of the duct
  101. 101. • The choice and technique of repair correlates with the success rate. • End-to-end anastomosisThe common duct (or common hepatic duct) has been divided and there is sufficient length to perform an end-toend anastomosis without tension
  102. 102. Unsuccessful : 1.When repaired at the initial open cholecystectomy 2. Class III injuries, especially laparoscopic. • The reasons for the high failure rate of end-toend biliary anastomoses relate to ischemia and tension.
  103. 103. Roux-en-Y hepaticojejunostomy • Has the best success rate for the repair of a transection injury of CBD/CHD
  104. 104. Certain technical factors for a successful hepaticojejunostomy are • Preoperative eradication of intra-abdominal infection • Viable ductal tissue (excise damaged ductal tissue) • Single-layer mucosa-to-mucosa anastomosis • Fine, monofilament, absorbable suture • Alleviate tension on the anastomoses
  105. 105. Stenting • Stenting is useful, however, when very small ducts are repaired (class IV injuries or class III injuries where the resection has been carried high into the porta). • For other injuries stenting may not be required.
  106. 106. WHEN DETECTED POST-OP….?
  107. 107. • The management of postoperative biliary strictures following ductal injury depends on the degree of injury, the presence of strictureinduced complications, and the operative risk of the patient.
  108. 108. • After recognition of a bile duct injury or stricture, a multidisciplinary team consisting of experienced interventional radiologists, endoscopists, and surgeons, coordinated by an experienced hepatobiliary surgeon, should plan the following specific goals: 1. Control the infection (abscess or cholangitis) 2. Drain the biloma 3. Complete the cholangiography 4. Provide definitive therapy with controlled reconstruction or stenting
  109. 109. OVERVIEW
  110. 110. Suspected CBD injury during lap-cholecystectomy Intra-op cholangiogram Partial injury(<30%) Extensive injury(>30%) Primary repair over T-tube Roux en Y choledochojejunostomy Roux en Y. Complete transection Injury to isolated hepatic duct >3mm Reimplantation or reconstruction by Roux en Y hepaticojejunostomy <3mm Ligate
  111. 111. Role of Interventional Radiology
  112. 112. • Interventional radiologic techniques are useful in patients with bile duct injuries, leaks, or postoperative strictures.
  113. 113. • These techniques allow 1)Percutaneous drainage of abdominal fluid collections 2)Preoperative identification of the ductal anatomy through percutaneous transhepatic cholangiography 3)Stricture dilation with or without placement of palliative stents for bile drainage in the patient whose overall physiologic status precludes a major operation.
  114. 114. • Percutaneous transhepatic biliary dilatation: – Intrahepatic ductal disease – ERCP is not possible – Adjunct to operative repair in order to assist with identification of the proximal biliary tree for reconstruction and for the dilation of anastomotic strictures
  115. 115. ROLE OF ENDOSCOPIC DILATATION IN BILIARY STRICTURES
  116. 116. • Adjunctive option in patents with a dominant extrahepatic stricture causing clinical symptoms. • Requires multiple sessions of dilations • Nonischemic strictures (anastomotic strictures) respond best.
  117. 117. • Metalic stents are more durable than plastic stents • Endoscopic dilation also has a low mortality rate, but it has a significant morbidity rate.
  118. 118. • Complications following endoscopic biliary interventions: – Hemobilia – Bile leak – Pancreatitis – Cholangitis – Re-stricture
  119. 119. POST-REPAIR COMPLICATIONS
  120. 120. 1. 2. 3. 4. 5. 6. 7. 8. Cholangitis Pancreatitis Stent occlusion Stent migration Ductal perforation Restricturing Biliary fistula Hemobilia
  121. 121. MANAGEMENT OF BILIARY FISTULA
  122. 122. • To define biliary fistula – ‘ a bilirubin rich drainage lasting for more than 5 days’ • Most of them resolve spontaneously with conservative management. • 3 R’S
  123. 123. 3 Rs • Resuscitation • Restitution • Rehabilitation
  124. 124. Resuscitation  The first stage in the management is the restoration of volume using crystalloid and colloid products as appropriate to restore oxygen carrying capacity and plasma oncotic pressure.  Blood PCV 30%  Albumin -3
  125. 125. • Control of sepsis • Per cutaneous drainage • Antibiotcs should only be given for defined infections and for a set duration of therapy • Nutritional support • Cholangiography
  126. 126. Non-operative management • Usually for low output fistula • Percutaneous drainage • Trans-hepatic stenting
  127. 127. Surgical intervention • For early high output fistula • Persistent sepsis Reoperation
  128. 128. References • • • • Surg Clin N Am 90 (2010) 787-802 Surg Clin N Am 88 (2008) 1329-1343 Schwartz's Principles of Surgery, 9e Sabiston Textbook of Surgery, 17e
  129. 129. THANK YOU

    Seja o primeiro a comentar

    Entre para ver os comentários

  • MOhammadAbdulRazek

    Dec. 30, 2019
  • shinashussainlives

    Jan. 12, 2020
  • koushikgowda3538

    Feb. 23, 2020
  • MasudRana349

    Apr. 11, 2020
  • zyxxo

    May. 10, 2020
  • BiswajitDevNath

    May. 15, 2020
  • NaveenKumar4179

    Jul. 21, 2020
  • VishalBansal1

    Jul. 21, 2020
  • AMonKyi

    Aug. 3, 2020
  • SajinaSaji4

    Aug. 4, 2020
  • smartyanil

    Aug. 9, 2020
  • AsmaFatimah1

    Sep. 16, 2020
  • drrajeevkmc

    Nov. 13, 2020
  • lakshminarayanansadhasivan

    Nov. 22, 2020
  • TharuniKatikaneni

    Dec. 9, 2020
  • ZuberiBeyan

    Feb. 13, 2021
  • yashvsinha

    Mar. 2, 2021
  • sandeepgupta1610

    May. 10, 2021
  • GunjanModgil

    Jul. 1, 2021
  • PoornarajSelvaraj3

    Jul. 7, 2021

Bile duct injuries

Vistos

Vistos totais

22.174

No Slideshare

0

De incorporações

0

Número de incorporações

13

Ações

Baixados

1.280

Compartilhados

0

Comentários

0

Curtir

85

×