Iatrogenic Biliary Injury Surgical Management

Abstract

Bile duct injury (BDI) remains a critical complication following cholecystectomy. Prevention, early recognition, and appropriate management can significantly improve patient outcomes. In this chapter, we will discuss the current review of the surgical management of BDI, including prevention techniques during the cholecystectomy, intra-operative diagnosis of the injury, early evaluation and imaging, importance and challenges of the referrals to a hepatobiliary center, types and classification of biliary injuries, biliary drainage, and interventional procedures bridging to definitive repair, timing of surgical repair-early versus late, surgical repair techniques, evaluation and management of combined vasculo-biliary injury.

1. Introduction

Laparoscopic cholecystectomy (LC) continues to be one of the most frequent surgical procedures performed in the US and the world, while bile duct injury (BDI) is the most morbid complication of LC [1]. Multiple preventive techniques reduced this complication rate [2], but BDI is still described in all LC’s at 0.1–0.5% range [3]. Due to the high numbers of cholecystectomies performed, it is an enormous healthcare problem often leading to long-term physical and psychological morbidity to patients, with mortality described up to 7% [4]. It also is associated with multiple interventions and hospitalizations that generate a significant cost and burden to the patient and healthcare system [5].

Prevention of BDI is of paramount importance. Over the years, various classifications of biliary injuries have been proposed, and different methods have been described to prevent iatrogenic biliary tract lesions. The optimal treatment is influenced by the timing of recognition of the injury, the extent of BDI, the patient’s clinical condition, and the availability of experienced hepatobiliary surgeons. This chapter aims to discuss the current updated management of iatrogenic BDI.

2. Safe cholecystectomy and prevention of BDI

2.1 Risk factors

Anatomical:

• Different variants of the cystic duct, such as short cystic duct, cystic duct running parallel to the common bile duct (CBD)

• Hepato-cystic duct

• Accessory cystic duct

• Aberrant bile ducts.

Patient-related:

• Acute or chronic inflammation

• Previous gastrointestinal or biliary surgery

• Obesity.

It has been demonstrated that the primary cause of BDI is the misinterpretation of biliary anatomy in 71–97% of all cases [6].

Over the years, various methods have been proposed and described to prevent iatrogenic biliary injury [7, 8, 9].

2.2 Surgical technique

2.2.1 Anatomical landmarks

• “Rouvière’s sulcus”-2–5 cm sulcus running to the right of liver hilum, anterior to the caudate lobe, containing the right portal triad or right posterior branches, and usually easily visible during the laparoscopy. It can be considered a useful landmark site to start dissection of the hepato-cystic triangle during LC, and “no-pass” point to prevent the injury of the right hepatic artery [10].

• “Cystic lymph node” or Mascagni’s node—always lies lateral to the biliary tree and should form the medial end point of dissection [11].

• “B-SAFE method”—by using five anatomic landmarks (B, bile duct; S, Rouvière’s sulcis; A, hepatic artery; F, umbilical fissure; E, enteric/duodenum) to guide the dissection [12].

• The “line of safety” (Figure 1)—an imaginary line which extends from Rouviere’s sulcus to the junction of the cystic and hilar plates, near the base of segment 4. It has been recently accepted as a relatively simple to define landmark representing the lower boundary for safe dissection [13].

Figure 1.

Line of safety is an important intra-operative landmark to prevent BDI.

2.2.2 Dissection approach

• Infundibular method—dissection close to gallbladder infundibulum, still carries a risk of identifying dilated cystic duct as an infundibulum, while identifying CBD as a cystic duct [2]

• Fundus first/dome-down technique—a way of dissection from the gallbladder fundus up to the infundibulum away from Calot’s triangle, so the gallbladder is left hanging on the cystic artery and cystic duct [14].

2.2.3 Final anatomical identification

The “critical view of safety (CVS)” technique (Figure 2) was introduced by Strasberg in 1995, and it is considered the gold standard to perform a safe cholecystectomy [9, 15]. It implies the identification of biliary structures during dissection and includes 3 criteria:

• The hepato-cystic triangle must be cleared of adipose and fibrotic tissues, and the CBD must not be exposed.

• The lower third of the gallbladder must be separated from the liver bed to expose the cystic plate.

• Two and only two structures should be seen entering the gallbladder.

Figure 2.

Critical view of safety is a “gold standard” anatomical confirmation for safe cholecystectomy.

2.3 Intra-operative tools

2.3.1 Intra-operative cholangiography (IOC)

It has been proposed for the better declaration of biliary anatomy, detection of silent CBD stones, and reduction of incidence of BDIs [16]. The opinions about the “routine” or “selective” use of IOC still represent a matter of debate, but the selective approach is considered to have comparable chances of preventing and detecting BDI [17, 18]. However, it is highly advised to use IOC in any case of difficult LC or when there is a concern about biliary anatomy identification [18, 19].

2.3.2 Intra-operative ultrasound (IOUS)

It was shown to provide a highly sensitive mapping of the extra-hepatic biliary anatomy [20], but the difficult learning curve and the lack of randomized controlled trials have reduced its use in clinical practice.

2.3.3 Fluorescent cholangiography

It represents a novel intra-operative imaging technique that allows real-time enhanced visualization of the extrahepatic biliary tree by fluorescence, after the intravenous injection of the dye indocyanine green (ICG) [21]. It is a safe and useful method that became a common practice in difficult cholecystectomy [22, 23]. However, under the conditions of severe inflammation, this imaging can be less clear, and then, a strong consideration to bail out is suggested (Figure 3).

Figure 3.

A real-time enhanced visualization of the extrahepatic biliary tree by fluorescence, after the intravenous injection of the dye indocyanine green (ICG).

2.4 When to bail out

“Inflection point”—the moment the decision is made to complete formal laparoscopic cholecystectomy [24].

The general rule is that it should happen sooner than later before the injury happens. The consequences of bailing out are usually less morbid than those of biliary injury.

The following factors may influence personal surgeon’s decision toward the inflection point [24, 25]:

• Personal experience

• Inability to establish biliary anatomy

• Lack of intra-operative imaging modalities

• Time since the incision—60 minutes in general or 1.5 times the personal median time for LC completion

• Lack of colleague second opinion.

2.5 How to bail out

2.5.1 Laparoscopic subtotal or partial cholecystectomy

2.5.1.1 Fenestration type - preferred method

Fenestration of the gallbladder anterior wall, leaving the posterior wall attached to the liver, ablating the mucosa, and securing the cystic duct at its origin from the mucosal side within the gallbladder [26].

Pros: usually easy recognition of the cystic duct origin, reduced blood loss with no need to dissect the gallbladder bed from the liver, usually no need for a conversion to open procedure.

2.5.1.2 Reconstitution type - optional method: resection of most of the gallbladder and leaving the small stump

Pros: can prevent BDI in complex cases.

Cons: risk for neo-gallbladder appearance, recurrent stones, possible need for cholecystectomy completion, which is likely more complex and high-risk compared to the index one.

2.5.2 Conversion to the open procedure

Pros: usually allows cholecystectomy completion, improved recognition of the anatomy including vascular structures [24, 25, 26].

Cons: morbidity related to the open incision, lack of experience of modern surgeons in open cholecystectomy.

A general recommendation is that in all cases of complicated cholecystectomies, the surgeon must not hesitate when considering bailing out from the completion of formal LC, because the consequences may be dramatic.

3. Diagnosis

3.1 Clinical presentation

Depending on the timing of diagnosis and type of injury, it can be divided as followings by pathophysiology:

3.1.1 Asymptomatic/at the time of LC

3.1.1.1 Biliary leak

• The evolution of the symptoms is a function of bile accumulation based on the severity of the leak and is very subtle.

• Symptoms are usually non-specific (nausea, vomiting, bloating, widespread abdominal pain, general discomfort, and anorexia) till the development of bile peritonitis and sepsis.

3.1.1.2 Biliary obstruction and stricture

• It may have a different natural course based on the degree of obstruction (complete/partial) and location of the lesion (proximal/distal bile duct, main/lobar bile duct).

• Symptoms include obstructive jaundice and/or cholangitis, with abdominal pain, jaundice, and signs of infection/sepsis.

3.2 Non-invasive imaging

Radiologic investigations should be obtained for the correct identification of the damage, its extension, and gravity and to plan therapeutic strategies.

3.2.1 Ultrasonography (US)

A primary and easily available diagnostic tool that allows finding fluid collections, dilation of the bile ducts, and possibly associated vascular lesions, using Doppler evaluation [27].

3.2.2 Computed tomography (CT)

Superior to the US in detecting fluid collections, and guiding their percutaneous drainage, but similar to the US is not reliable in distinguishing bile leaks from other postoperative fluid collections, such as blood, pus, or serous fluid, because of their similar densities [28, 29, 30]. It can also show biliary obstruction with upstream dilatation, or long-term sequelae of a long-standing bile stricture, such as lobar hepatic atrophy or signs of secondary biliary cirrhosis. The CT scan is specifically useful to identify any associated vascular lesions.

3.2.3 Hepatobiliary scintigraphy (HS)

It seems to be more sensitive and specific than US or CT in detecting bile leaks and can provide functional information demonstrating the presence of an active leak [31]. However, its spatial resolution is poor, and the identification of the leak site can be challenging. In addition, it is limited in providing the exact anatomy of the whole biliary tree and in patients with hepatic dysfunction, and large leaks have poor sensitivity and can show no extrahepatic bile duct [32]. Because of those limitations, it is rarely used as a standalone test, and its use is replaced mostly by magnetic resonance imaging.

3.2.4 Magnetic resonance imaging with cholangiopancreatography (MRI/MRCP)

A non-invasive “gold standard” for the complete morphological evaluation of the biliary tree as it offers detailed information about the integrity of the biliary tract [28, 33]. The use of a gadolinium contrast agent during MRI/MRCP allows the detection of active bile leakage by direct visualization of contrast material extravasation into fluid collections in addition to demonstrating the anatomical site of the leakage and the type of BDI, and thus, it is superior to CT and US in specifying the collection as biloma [34, 35].

3.3 Invasive cholangiography

3.3.1 Types used

• Endoscopic retrograde cholangiopancreatography (ERCP) [32]

• Percutaneous transhepatic cholangiography (PTC)

• Intra-operative cholangiography (IOC).

3.3.2 General advantages

• A “gold standard” in identifying the presence of BDI and its type

• Provide exact biliary anatomy

• Allows the treatment of the injury by stenting and/or biliary drainage.

3.3.3 General disadvantages

• Nonnegligible risk of complications

• Lack of detection of extra biliary abnormality and surgical complications

• Non-visualization of the biliary tree upstream or downstream of the lesion—in case of complete transection or obstruction of the bile duct may require both ERCP and PTC to complete the biliary anatomy.

3.3.4 Specific considerations

3.3.4.1 ERCP

• Treatment of bile leak by papillotomy and pressure reduction and stenting [32, 36]

• In advanced injury as bridging till definitive repair in advanced

• In low-grade injury, usually with biliary opening less than 5 mm, as a definite treatment with no need for surgical repair

• Treatment of biliary obstruction by stenting

• Complications: pancreatitis, bleeding, and cholangitis.

3.3.4.2 PTC

• Usually requires dilation of the biliary tree, so easier to apply when some degree of biliary obstruction is present [37, 38]

• Treatment of bile leak by diversion of the bile flow

• When ERCP is not possible or not successful

• In the complete transection of the bile duct

• Treatment of biliary obstruction by diversion of the bile flow and stenting

• Recent experience showed satisfactory results with performing an extraluminal percutaneous endoscopic rendezvous procedure with stent placement to restore continuity of the bile duct [38, 39]. This procedure should be considered with caution, as it carries a risk for significant complications such as choledochoduodenal fistula [40].

• Complications: bleeding and cholangitis.

4. Classification

The location of BDI on the biliary tree is of primary importance in deciding management and predicting outcomes. We suggest using classification introduced by Strasberg in 1995 [7], as its comprehensive anatomical and functional injury description allows repair guidance and stratifies the risk for long-term complications, such as biliary stricture [41].

Figure 4 Strasberg classification.

Figure 4.

Strasberg’s classification of BDI.

Type A: bile leakage from either the minor bile ducts from gallbladder bed or the cystic duct.

Type B and C: occlusion (type B) or transection (type C) of aberrant right hepatic ducts.

Type D: lateral damage to the common bile duct resulting in a biliary leak.

Type E: involve the main ducts and are classified according to the level of injury in the biliary tree. Each type corresponds to the same type of Bismuth classification:

E1 - >2 cm from the confluence.

E2 - <2 cm from the confluence.

E3 - in the hilum, right and left duct are not separated.

E4 - in the hilum, right and left duct are separated.

E5 - in the hilum, combined with type C.

5. Timing of diagnosis and repair

Early and delayed repair are both acceptable approaches to a definite repair of BDI. The big question exists regarding an exact definition of “early” vs. “delayed”. The data is mixed, and the time from the initial surgery is defined as between 0 and 21 days for early [5, 8, 12, 13] and after 4–6 weeks as “delayed” [8, 12].

Advantages of early approach:

• Reduced inflammation—if done early enough

• Decreased morbidity of temporary biliary drainage

• Decreased psychological trauma to the patient

• Faster recovery and a quicker return to the regular lifestyle.

Advantages of delayed approach:

• More detailed diagnosis of the degree and type of BDI

• Reduction in inflammation

• Improved anatomic visualization

• Delay allows undiagnosed associated vascular injuries to be identified.

• Provides the surgeon a better roadmap for developing an operative plan for definitive reconstruction.

5.1 Choice of the early versus delayed repair

5.1.1 Timing

Based on most recent evidence, we recommend considering early repair within 48–72 hours from the injury [40, 42, 43]. Some data suggests the earlier the repair, the better the results [4, 44, 45] whereas other support comparable good outcomes within 72 hours timeframe [46].

When missed the opportunity window of 48–72 hours for an early repair, it is advised to delay it for at least 4–6 weeks [37, 43, 47]. This will allow to decrease the degree of local inflammation, control infection, and optimize the conditions for a complex reconstruction.

5.1.2 Expertise

The repair of a bile duct injury is a complicated procedure, and there is clear evidence that the best results are obtained at a center with experienced hepatobiliary surgeons [43, 48, 49, 50]. It is a single most important factor in the success of the repair. At attempt to perform an immediate repair by an unexperienced surgeon is associated with worse outcomes and can compromise the future repair by a specialist, in case of repair complications [43, 50].

5.1.3 Type of injury

In the presence or suspicion for a vascular injury, one should consider delaying a repair to complete a comprehensive work-up and to allow the injury present and establish its clinical significance [43, 51].

5.2 Early repair

5.2.1 Immediate recognition of the injury at the time of LC

After the prevention of the injury, the surgeon’s awareness to suspect and evaluate for a BDI is the second most important factor in determining the patient prognosis.

5.2.1.1 Immediate intra-operative repair

If the required surgical expertise is present, we suggest following steps:

1. Conversion to an open procedure

2. Careful surgical exploration and identification of important structures and the injury

3. Confirmation of injury type with intra-operative cholangiography

4. The preference is to image both proximal and distal direction of the biliary tree if possible.

5. Consider IOUS if vascular injury is suspected [51]

6. Immediate repair according to the type of injury.

5.2.1.2 Early transfer to a tertiary referral center

If the competent surgeon capable of performing a biliary reconstruction is not present, we advise to follow the next steps:

1. DO NOT convert to an open procedure. This may expose the patient to an additional morbidity and make the definite repair more complicated [43, 48, 50]. The acceptable reason to convert may be bleeding difficult to control laparoscopically.

2. If possible, evaluate the injury type by intra-operative cholangiogram.

3. Place a drain [52].

4. Transfer a patient as soon as possible to a tertiary hepatobiliary referral center—that provides better outcomes that immediate repair by less experienced surgeon.

5. Provide as much relevant information as possible with the referral. Additional imaging, such as MRI/MRCP, can be performed while waiting for a transfer.

5.2.2 Early recognition after completion of cholecystectomy

At the same admission it presents as described earlier symptoms and signs of biliary leak, obstruction, or both. A general recommendation is that any alteration in the normal postoperative course after LC must suggest a possible damage to the biliary tract. Sometimes, the evolution of biliary symptoms is subtle, so high degree of clinical suspicion and careful clinical evaluation of patients are essential. It will allow the thorough and prompt inpatient evaluation and/or referral to a tertiary specialty center.

The diagnosis after the discharge is often made based on clinical symptoms, which means more advanced and complicated problem, or based on abnormal lab tests, in case of milder injury.

To allow the chance of early repair, one should apply similar principles as described in case of intra-operative injury recognition:

5.2.2.1 Perform prompt biliary imaging to evaluate the type of the injury and provide the drainage of biliary system

US:

• Initial imaging

• Identification of biliary dilatation, fluid collections, and vascular injuries by Doppler.

MRCP:

• First-line non-invasive imaging.

• Can be confirmatory for the type of injury.

CT:

• Important to rule out associated vascular injury

• Allows imaging-guided percutaneous drainage of the collections.

ERCP:

• First-line confirmatory biliary imaging.

• Allows drainage and stenting.

• In mild grade injuries (A-D) can be sufficient as the only treatment with no need for operative intervention.

PTC:

• First-line procedure for drainage and stenting when MRI/MRCP confirms complete transection or obstruction of the bile ducts

• Usually needed in type E injuries is temporary bridging treatment till the delayed repair [40]

• Second-line procedure for drainage and stenting if ERCP not feasible.

Drain any biloma or abscess percutaneously if operative drain is not present or is not providing adequate drainage—to prevent and treat bile peritonitis and sepsis, as well as to control the ongoing leak [52].

5.2.2.2 Make the decision about the possibility of early repair, based on factors discussed earlier

• Presence of competent hepatobiliary surgeon

• Timing of the diagnosis—up to 72 hours from the injury

• Absence of vascular injury.

5.3 Delayed repair

5.3.1 The conditions leading to choosing the delayed repair approach

• Late recognition—beyond 72 hours from the injury

• Need for a comprehensive work-up to determine the type and degree of the injury

• Delays in transfer to a referral hepatobiliary center, related to geographic distance, transportation resources, and bed availability [40, 53]

• Patient hemodynamic instability or uncontrolled sepsis [52]

• Patient complex medical background requiring pre-operative optimization [40].

6. Management and repair of minor BDI—types A-D

6.1 Type A injury

6.1.1 Non-operative management

• Draining an abdominal collection and controlling a leak alone may be a sufficient treatment [49, 52, 54]

• If the leak is not controlled by a drainage alone, proceed with ERCP, which success in the minor BDI with low output leaks is between 87% and 100% [49, 55, 56, 57, 58, 59, 60].

6.1.2 Operative repair

• The operative intervention reserved for minority of the cases, where the leak is not resolving after ERCP and drainage or when discovered intra-operatively

• Technique—surgical ligation of a cystic duct stump or oversewing an accessory duct at the gallbladder bed provides simple and reliable solution.

6.2 Type B injury

6.2.1 Non-operative management

• Is appropriate when a segmental or accessory ligated duct is small (usually up to 3 mm) and cholangiography demonstrates adequate drainage of the segment with an injured bile duct.

• Temporary percutaneous drainage (PTC) can be placed to control cholangitis in the obstructed segment.

6.2.2 Operative repair

• Is warranted if the injured duct is bigger (more than 3 mm), drain multiple hepatic segments, no adequate drainage is confirmed by cholangiography or if there is recurrent cholangitis is present despite maximal percutaneous drainage

• Reconstruction of injured duct by Roux n Y Hepato-Jejunostomy—when duct is bigger, and reconstruction is technically feasible

• Hepatic resection of the obstructed segment to control recurrent cholangitis—when reconstruction is not feasible.

6.3 Type C injury

6.3.1 Non-operative management

• Is appropriate when segmental or accessory leaking duct is small (up to 2–3 mm), cholangiography demonstrates adequate drainage of the segment with an injured bile duct.

• Temporary endoscopic or percutaneous drainage may be required to control the leak.

6.3.2 Operative repair

• Ligation of injured duct—when the duct is small and adequate segmental drainage confirmed by cholangiography, but the leak is not controlled.

• Reconstruction of injured duct by Roux n Y Hepato-Jejunostomy—when the duct is large, and no adequate drainage is confirmed by cholangiography.

Injuries grade D and above usually will require operative intervention.

6.4 Type D injury

6.4.1 Non-operative management

• ERCP with papillotomy and possible stenting can be appropriate when the side injury of the bile duct is small, usually less than 5 mm, and the leak is low output [49, 56].

• Can be attempted on the high-output leaks as well, but the chance for success with endoscopic treatment only is low [54]

• In addition, an abdominal drain for controlling the leak should be placed [49, 54].

6.4.2 Operative repair

• Is recommended if recognized intra-operatively, after the failure of endoscopic treatment or large injury and leak are demonstrated on the imaging [49, 56, 57, 58]

• Usually, the choledochotomy can be repaired primarily with 5–0 or 6–0 absorbable sutures.

• In case of very large side injury, debridement of the duct may be required and primary duct-to-duct anastomosis with healthy duct edges performed [45, 60].

• Consider surgical or endoscopic stenting in addition to the surgical repair [45, 61, 62].

7. Management and repair of major BDI—types E injury (transection, clipping, or stricture of major bile ducts)

7.1 Non-operative management

7.1.1 ERCP

• Rarely can be successful as a standalone management without surgical reconstruction and is associated with high morbidity [54, 63]

• Consider as an alternative for surgical reconstruction in patients with very-high perioperative risk due to medical co-morbidities and surgical history [40]

• Can be attempted when there is at least partially documented MRCP confirmed of the bile duct, or a very close proximity of the proximal and distal biliary stumps two biliary stumps [64]

• This should be performed only by highly experienced biliary endoscopist, as it might carry the risk for significant morbidity endoscopists [40, 60, 63, 64].

• Although less investigated in the literature, long-term (at 10 years) outcomes of endoscopic treatment with stent placement appeared to be good and effective in patients with postoperative biliary strictures [65, 66, 67].

7.1.2 PTC

• A necessary and effective bridging biliary procedure while waiting for a delayed repair [40, 67, 68]

• Specifically successful in cases of complete obstruction of the bile duct, or when a significant stricture present, and ERCP is not successful or feasible [67, 68]

• PTC in the presence of bile leakage may be more difficult because of non-dilated bile ducts but still leads to a technical success of 90% and a short-term clinical success of 70–80% in expertise centers [67, 68, 69].

7.2 Primary anastomosis of the bile duct-choledocholedochostomy

7.2.1 Why to attempt-advantages on bilioenteric reconstruction

• Less technically complex

• Shorter operative time-important in case the patient is septic or unstable.

• Less short-term post-operative complications [70].

• Allows favorable access for endoscopic treatment of anastomotic complications.

7.2.2 Can be performed in selected cases-conditions to perform

• If there is no significant loss of bile duct tissue (usually less than 1 cm)

• Proximal and distal biliary stump ends can be opposed without tension.

• Recommended in settings of early reconstruction only, usually not feasible in a delayed fashion, as the chronic inflammation and fibrosis interferes with an ability to perform tension free repair [57, 71]

• When no vascular injury is present

7.2.3 An exceptional clinical judgment is required to decide about the primary bile duct

reconstruction as this approach is associated with increased failure rate compared to bilioenteric reconstruction, especially when it is performed beyond the conditions mentioned above [50, 57, 72].

7.2.4 Choledocholedochostomy-operative technique

• Debridement of bile duct ends, till getting satisfactory healthy tissue

• Extended Kocher maneuver can help with mobilization of a distal bile duct and allow approximation of both ends

• Consider placement of biliary stent or T-tube

• Performing an end-to-end fashion anastomosis with absorbable sutures.

• Drain placement.

7.3 Bilioenteric reconstruction—Roux-en-Y hepatojejunostomy

It represents a gold standard surgical repair of major bile duct injuries and is being performed as a definite repair in most cases of BDI [7, 43, 49, 73]

7.3.1 Advantages

• Allows resection of the bile duct and performing high biliary anastomosis

• It which carries better blood supply by communicating vessels from peribiliary plexus at the level of biliary bifurcation, which usually remain intact even after high grade BDI

• Allows tension-free anastomosis

• Overall, less anastomotic complication and reduced need for reoperation than the primary bile duct repair [50, 57, 72, 73, 74].

7.3.2 Roux-en-Y Hepato-jejunostomy-surgical technique

• Closure of the distal bile duct stump

• Proximal small bowel Roux limb creation

• Placement of biliary stent through the anastomosis

• End-to-side or side-to-side proximal bile duct-to-bowel anastomosis with absorbable sutures

• Creation of Y limb and jejunojejunostomy (Figure 5).

Figure 5.

Roux-en-Y Hepato-jejunostomy - surgical technique.

7.3.3 The details of repair vary depending upon the grade of the injury

7.3.3.1 Type E1–2

Single duct bilioenteric anastomosis.

7.3.3.2 Type E3

• If the bile duct bifurcation maintained as a single orifice allowing technically feasible reconstruction—can perform single bilioenteric anastomosis

• If not, two separate right and left anastomoses should be performed.

7.3.3.3 Type E4

• Two separate right and left biliary enteric anastomoses are usually required.

• As an alternative both biliary branches can be reconstructed together as a single orifice.

• In rare cases, suitable duct length outside the hepatic parenchyma cannot be obtained, these cases necessitate isolation of the intrahepatic biliary system, and IOUS may be necessary in these situations.

7.3.3.4 Type E5

• Principles of E4 type are applied.

• The additional duct may be ligated or reconstructed based on the principles for segmental accessory duct injury management, described earlier.

7.3.3.5 Technical solutions in complicated cases

• In order to achieve sufficient bile duct caliber side-to-side technique may be preferred, including opening the left hepatic duct but keeping the posterior wall of the bifurcation to preserve the blood supply, according to the Hepp-Couinaud technique [75, 76].

8. Vasculobiliary injury (VBI)

This is defined as a combined injury to a bile duct and to an accompanying major blood vessels in the porta hepatis.

Types of VBI [75]:

• Classic (over 90% of VBI)—Right hepatic artery (RHA) injury

• Extreme (less than 10% of VBI)—Combined RHA and main or right portal vein (PV) injury.

8.1 Classic VBI

8.1.1 Injury to the RHA below the biliary confluence (usually type E1/E2)

Does not usually cause a clinically significant ischemic injury to the liver parenchyma, due to a shunt that occurs immediately from the left hepatic artery (LHA) traveling via the transverse hilar marginal artery (THMA) to the right liver [76].

8.1.2 Injury to the RHA above the biliary confluence of the ducts

• Will disrupt the collateral biliary blood supply including THMA.

• Possible clinical presentations include development of small areas of right hepatic lobe ischemia with possible subsequent abscesses formation.

• Chronic atrophy of the right hepatic lobe, which is usually clinically unsignificant due to intact portal blood supply.

8.2 Impact of VBI on definite repair approach

8.2.1 Diagnosis

• US with Doppler can provide some information.

• CT scan with IV contrast usually required as a part of work-up for high-grade biliary injury (types E) to rule out.

• High level of suspicion for VBI, based on high grade biliary injury or intra-operative bleeding will mandate the imaging work-up, making the immediate repair unlikely.

8.2.2 Timing of repair

• VBI increases the risk for repair stenosis repair should not be neglected as it will lead to extensive morbidity and the need for endoscopic or percutaneous interventions [75].

• In severe and untreated cases, it can lead to late biliary cirrhosis with portal hypertension.

• To avoid this the repair should be delayed for several weeks to allow the ischemic injury to delineate and ensure the anastomosis is done to well vascularized tissue.

8.2.3 Surgical approach to repair

• Avoid primary duct to duct anastomosis [71, 75].

• Hepaticojejunostomy is the repair of choice.

• A resection of extrahepatic bile duct and the anastomosis at the level of bifurcation is preferred—to achieve adequately perfused margins.

• While lowering the hilar plate to achieve sufficient proximal biliary stump, care should be taken to avoid additional devascularization of peribiliary vascular plexus.

• Described above side-to-side hepato-jejunostomy technique can provide a solution for creation of wide and well-vascularized anastomosis.

8.2.4 Arterial reconstruction

• Usually, it is not possible to reconstruct the RHA and indeed it is not necessary, because of little clinical significance of liver disfunction.

8.2.5 Outcomes

• With the right surgical classic VBI can be managed with the outcomes comparable to BDI without vascular injury [40].

8.3 Extreme VBI

• Rare and devastating injury

• Can be associated with “dome-down” approach to a shrunken gallbladder which results in massive bleeding from both the portal vein and hepatic artery [77].

• The main priority—bleeding control

• As opposed to arterial injury, the likelihood of hepatic ischemia is high in PV injury.

• It can require right hepatectomy in case of RPV injury or PV reconstruction and even liver transplantation in case of main PV injury.

• In this scenario, the short- and long-term outcomes are dismal with up to 60% mortality risk [78].

9. Conclusions

• Bile duct injury (BDI) remains a critical complication following cholecystectomy.

• Early recognition and appropriate management can significantly improve patient outcomes.

• Prevention of biliary injury during cholecystectomy is of paramount importance and includes recognition of anatomical landmarks and a critical view of safety achievement, precise surgical technique, use of intra-operative imaging, and timely bailing out from a completion of a standard laparoscopic cholecystectomy.

• Diagnosis of biliary injury is made based on clinical picture of biliary leak or obstruction, ultrasonography, cross-sectional imaging, and cholangiography.

• Strasberg classification of BDI is the most comprehensive to define the type and extent of the injury and guide the surgical repair.

• Early and delayed repair are both acceptable approaches to a definite repair of BDI. We recommend choosing an early repair up to 72 hours from the injury and if missed this opportunity, to delay it for at least 4 weeks.

• The BDI repair should be performed by an experienced Hepato-Pancreato-Biliary surgeon, and thus, the presence of such an expertise is the most important factor in deciding the timing of the repair.

• If needed, early and organized referral to a tertiary center is the first time limiting critical step of BDI management.

• Intraoperative recognition of the injury allows the best chance for an early repair and can prevent the morbidity associated with a delayed repair.

• Prior to a decision for the repair, the complete understanding of biliary anatomy and injury type is required and can be achieved by MRI/MRCP, ERCP or PTC.

• The latter two are also important for a temporary control of biliary injury.

• PTC is particularly useful as a bridging treatment for high-grade injuries with a loss of biliary continuity while waiting for a delayed repair.

• As a part of surgical management, the intra-abdominal biliary sepsis and leak should be controlled with appropriate drainage.

• The definite surgical management of low-grade Strasberg types A-D injuries can include biliary drainage only, primary repair of the bile duct or duct-to-duct biliary reconstruction.

• In cases of significant bile duct tissue loss and tension associated with primary repair, bilioenteric reconstruction with Roux-en-Y hepato-jejunostomy is recommended.

• High-grade Strasberg type E injuries should be always repaired with Roux-en-Y hepatojejunostomy.

• The proper surgical technique allowing reconstruction of healthy and well-vascularized bile duct is an absolute condition for a success and long-term patency of the repair, so the resection of the extrahepatic bile duct and high anastomosis at the level of biliary bifurcation is always preferred.

• Associate vascular injury defined as vasculobiliary injury (VBI) should be always ruled out in BDI evaluation.

• Most common is right hepatic artery injury and it mandates delaying the definite surgical repair to allow the ischemic injury to delineate and ensure the anastomosis is done to well-vascularized tissue.

• With appropriate management, comparable outcomes to BDI without vascular injury can be achieved.

• Rare and devastating portal vein injuries often require partial liver resections and are associated with high morbidity and mortality.

Acknowledgments

Chirag S Desai, MD, University of North Carolina at Chapel Hill, Division of Abdominal Transplantation for the mentorship, guidance, and friendship.

Thanks

Thanks to my family, colleagues, and mentors, this book chapter publishing would not be possible without their support.