This document describes the medical history and treatment of a 50-year-old female patient who presented with right upper quadrant pain and was diagnosed with cholelithiasis. She underwent an open cholecystectomy but was later readmitted with signs of bile duct injury, which was repaired during a second surgery. The patient was discharged after the drainage from her bile duct decreased sufficiently over a two week follow up period.

2. BY : DR MUHAMMAD UMAR NISAR
PGT (SURGERY)

3.  PATIENT: XYZ
 AGE: 50YRS
 GENDER: FEMALE
 RESIDENCE: sarghoda
 D.O.A: 27-07-2015
9/21/2015 3

4. known diabetic – 16 years
 Off and on Pain in RHC – 03 years
 Off and on nausea/ vomiting - 03 years
9/21/2015 4

5.  PAST HX: C section – 1 year back
 SYSTEMIC HX:
 FAMILY HX: NAD
 PERSONAL HX:

6.  50 years Old lady lying comfortabely in bed
well oriented in time place and person.
 B.P : 130/80 mmHg
 Pulse : 82/min
 Temp : Afebrile
 R.R : 19/min

7.  Pallor : absent
 Cyanosis : absent
 Jaundice : absent
 Thyroid : not enlarge
 Edema : absent
 Lymph node : not palpable

8.  Chest:
 CNS
 CVS
 Abdomen:
◦ Soft
◦ Non tender
◦ No visceromegaly
◦ BS present
NAD

9.  Blood CP :
◦ Hb = 11.6 mg/dl ,
◦ WBC,s = 6.21 X 109/l
◦ Platelets = 177x 109 /l
 RFTs = WNL
 LFTs = WNL
 BSR= 16.1mmol/l
 Urine RE= Normal
9/21/2015 9

10. Ultrasound AbdomenChest XRAY
 CholelithiasisNormal study

11.  Open cholecystectomy was done on 29-
07-2015
 Abdomen was opened via right upper
transverse incision
 Per op findings were thick walled gall
bladder and omental adhesions
 Cystic artery ligated
 Cystic duct tied
 Gall bladder was removed
 Homeostasis secured, abdomen closed

12.  Patient was stable vitally
 Abdomen was soft and there was tenderness
at wound site
 Patient was discharged 2 days after surgery

13.  Patient presented again in emergency on 5th
Aug 2015 with C/O
◦ Pain RHC
◦ Abdominal distention
◦ Nausea and anorexia
◦ Yellowish discoloration of sclera
◦ Clay colored stool and dark color urine
 GPE:
◦ Anemia : present
◦ Jaundice : present

14.  Abdomen
◦ Rt upper transverse scar of cholecystectomy
◦ Distended
◦ Tender
◦ Guarding
◦ BS +ve

15.  Blood CP :
◦ Hb = 8.6 g/dl ,
◦ WBC,s = 16.21 X 109/l
◦ Platelets = 442x 109 /l
 RFTs =
◦ Urea: 18.4mmol/l
◦ Creat: 314 mmol/l
 LFTs =
◦ Bili: 55 umol/l
 BSR= 252 mg/dl
 Coagulation profile:
WNL
 Serum Amylase: WNL

16.  Abdomen was opened via previous scar.
 Suction of almost 2L of bile was done.
 Per op findings were transected CBD at cystic
duct level with proximal stump of about 3-
4cm from confluence and distal stump was
approx 2-3 cm.
 Peritoneal cavity washed with 8L of fluid.
 CBD stent placed inside the CBD and end to
end anastomosis done with vicryl 6/0.
 Drains placed in RHC and in Pelvis.
 Abdomen closed
 ASD done

17.  Kept in ICU for 2 days and in ward for 8 days
with daily output in RHC drain of 500-800ml
 Thus the patient is considered to be managed
on the lines of controlled biliary fistula
 Discharged on 12th POD with RHC drain in
place
 Advised follow up after 2 weeks
 First post op visit:
◦ Daily output in drain= 400-600ml
◦ Abd: soft, non tender
◦ LFTs: bili- 26 umol/l
◦ Coag : WNL

19.  Bile duct injuries represent a complex
clinical scenario seen with increased
frequency owing to
◦ aberrant anatomy
◦ more lap cholecystectomies being
performed
 Incidence :
◦ 0.1-0.2 % in open cholecystectomy
◦ 0.4-0.6 % in lap cholecystectomy

21.  Earliest known gall stones - Priestess
of Arnan (1085-945 BC) – Egyptian
 The first clinical description of
gallstone disease - Gordon Taylor, in
his description of the symptoms
manifested by Alexander the Great in
323 BC

22.  John Stough
Bobbs - first
elective
cholecystostomy
in Indianapolis
for hydrops of
the gallbladder
 In 1878 Kocher
drained an
empyema of
gallbladder.

23.  Ludwig George
Courvoisier (1843-
1918).
◦ Law (Statistical
article on the
pathology and
surgery of the biliary
system)
◦ First
choledocholithotomy

24. First open cholecystectomy
•Dr Carl Johann
August Langenbuch
(German surgeon)
•July 15, 1882, at
Lazarus
Krankenhaus in
Berlin

25.  Hans Kehr –
invented a T
tube
First laparoscopic
cholecystectomy
 Erich Mühe in
Germany in 1985

28.  The cranial segments :
cystic artery and the hepatic
arteries, especially the right (R)
hepatic artery.
 The caudal segment:
pancreaticoduodenal artery
through the retroduodenal artery.
 The middle segment :
is vascularized by an axial
network of a varying number of
arterial anastomoses between
the cranial and caudal supplies.

29.  60% by the distal vessels
 38% by the cranial ones
 2% by a nonaxial supply from common
hepatic artery
 This arterial pattern predisposes the
supraduodenal segment of the common
bile duct to ischemic damage and resulting
in strictures.

30.  space bordered by:
◦ Cystic duct inferiorly,
◦ Common hepatic
artery medially
◦ Superior border of
the cystic artery

33.  Iatrogenic injury
 Cholecystectomy
 Gastrectomy
 Pancreatectomy
 ERCP
 Trauma

34.  Inflammation in the porta,
 Variable biliary anatomy,
 Inappropriate exposure,
 Aggressive attempts at hemostasis,
 Surgeon inexperience.
97% due to visual misperception, only 3% accounts for
technical skills and knowledge.

35. Misperception ..
With sufficient cephalad retraction of the gall
bladder fundus ,the cystic duct overlies the
common hepatc duct running in a parrellel path.
without inferolateral traction of the gallbladder
infundibulum to dossociate this structures, the
dissection of apparent cystic duct may actually
include CBD…

36.  Acute inflammation and scarring of the
triangle of calot.
 Acute cholecystitis.
 Acute pancreatitis.
 Chronic cholecystitis.
 Mirizzi syndrome
 Perforated duodenal ulcer.

37.  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.

38.  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.

39.  Use of electrocautery
 Avoided near the CBD
 Bipolar cautery is better.
 Avoid usage near metallic clips
 Low intensity for short duration

40. CLASSIFICATION

41.  Era of Open Chole
 Based upon level of biliary strictures with
respect to hepatic bifurcation
 Type 1-5.
 Helps surgeon choose appropriate site for
repair

43. A drawback of the
Bismuth
classification is
that patients with
limited strictures,
isolated right
hepatic duct
strictures, or cystic
duct leaks cannot
be classified

44. Strasberg
classification is
able to classify
all types of injury
and is used
extensively in
describing bile
duct injuries
associated with
laparoscopic
cholecystectomy

45.  BL from minor duct
◦ Cystic duct leak
◦ Liver bed leak
◦ Accessory duct leak
 Communication between liver and
duodenum via major ducts unaffected

46.  Occlusion of the part of
biliary tree
 Usually due to Rt
abberant duct ligature
 May be
segmental,sectorial,
main RHD

47.  Transection of aberrant
right hepatic ducts
 Similar to B but…
 Presents and treated
differently
from B

48.  Lateral injury to main
extrahepatic bile ducts
 Similar to A
◦ Bile collection
 Dissimilar to A
◦ Location on the main biliary
tree
◦ Consequences more severe
 RHD, CHD, CBD may be
involved

49. 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

50.  McMahon
 Amsterdam Academic Medical Center's
classification (1996)
 Neuhaus' classification (2000)
 Csendes' classification (2001)
 CUHK (Chinese University of Hong Kong),
2007

52.  The common clinical symptoms are jaundice,
fever, chills, and epigastric pain.
 divided into two groups.
 patients with bile leaks, If the subhepatic
region is not drained, subhepatic bile
collection (biloma) or abscess develops.
◦ fever, abdominal pain and other signs of sepsis
occur.
◦ Generally, jaundice is not observed in these patients
because cholestasis does not appear.
 patients with biliary strictures, jaundice is the
commonest clinical symptom caused by
cholestasis .

54.  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.

55.  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

56.  Clipped duct is not fully encompassed by
a standard clip (9mm)
 Presence of another unexpected ductal
structure
 A large artery (RHA) behind the duct
 Extra lymphatic &vascular structure seen
 Proximal hepatic ducts fail to opacify on
IOC

57. ◦ Second cystic artery, this may be the right
hepatic artery
◦ Lymphatics surrounding the 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

59.  Proper selection of cases
 In LC of obese patients, place the
optical port little higher up from the
umbilicus to avoid the tangential view
of the Calot’s triangle.
 Always dissect to the right of the line
joining the right free margin of lesser
omentum to cystic node.

60.  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”.

61.  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

62.  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 abnormally superficial right
anterior sectoral duct.

63.  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

64.  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.

65. In case of excessive bleeding during
the lap 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.

67. HOW ESSENTIAL IS TO TREAT
BILE DUCT INJURIES?

68.  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.

69.  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 long-term
success rate.

70. WHAT ARE THE FACTORS ONE SHOULD
CONSIDER BEFORE TREATING BILE
DUCT INJURIES?

71. 1.Timing of diagnosis
◦ Intra-operative
◦ Early post-op
◦ Late post-op
2.Extent and level of injury
3.Patient presentation
4.Hospital setup

72. WHAT ARE THE TREATMENT
OPTIONS AVAILABLE ?

73. 1) Surgical Management
2) Interventional Radiologic Techniques
3) Endoscopic Techniques
 Most of these injuries and strictures are best
repaired surgically.
SURGERY - GOLD STANDARD

74.  A multidisciplinary approach
 The team consisting of experienced
interventional radiologists, endoscopists, and
surgeons, coordinated by an experienced
hepatobiliary surgeon

75. PRE-OPERATIVE MANAGEMENT

76.  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

77.  Next step-
Pre-op cholangiography (to define anatomy)
Control bile leak with percutaneous stents
Delayed surgical repair

78.  Late post-op period
 Strictures
 Cholangitis
 Treat with- Broad spectrum antibiotics
Urgent cholangiography
Biliary decompression
Transhepatic biliary drainage
Endoscopic drainage + stent
Surgical repair

79.  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

80.  Sahajpal et el
 retrospective medical record review of 69
patients who underwent repair after LC-
BDIs
BDIs were classified into 3 groups based on
timing of repair from time of injury.
◦ Immediate repair (0-72 hours of LC)
◦ Intermediate (between72 hours and 6weeks after
LC)
◦ Late (after 6weeks)
 Patients who underwent repairs in the
intermediate period were at a significantly
higher risk of developing biliary stricture

81.  De Reuver et al investigated the influence of
timing of repair on outcome
 3 groups of patients were defined.
◦ Acute repair: Within 6 weeks
◦ Delayed repair: After 6 weeks
◦ Late Repair:
 Repair in the acute phase after injury is
associated with long term stricture formation.

82. INTRA OPERATIVE MANAGEMENT

83.  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

84.  Injury involves <50% of the circumference of
the bile duct wall
Primary closure over a T-tube

85.  More extensive biliary injury
 Significant thermal damage owing to
cautery-based 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

86. MANAGEMENT OF HEPATIC DUCT
INJURIES

87.  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.

89.  The choice and technique of repair
correlates with the success rate.
 End-to-end anastomosis-
The common duct (or common
hepatic duct) has been divided and
there is sufficient length to perform an
end-to-end anastomosis without
tension

90. Unsuccessful :
1.When repaired at the initial open
cholecystectomy
 The reasons for the high failure rate of end-
to-end biliary anastomoses relate to ischemia
and tension.

91. Roux-en-Y hepaticojejunostomy
 Has the best success
rate for the repair of
a transection injury of
CBD/CHD

92. 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

93. Stenting
 Stenting is useful, however, when very
small ducts are repaired
 For other injuries stenting may not be
required.

94. OVERVIEW

95. Suspected CBD injury during lap-cholecystectomy
Intra-op cholangiogram
Partial injury(<30%) Primary repair over T-tube
Extensive injury(>30%) Roux en Y
choledochojejunostomy
Complete transection Roux en Y.
Injury to isolated hepatic duct
>3mm Reimplantation or reconstruction
by Roux en Y hepaticojejunostomy
<3mm Ligate

96. Role of Interventional Radiology

97.  Interventional
radiologic
techniques are
useful in patients
with bile duct
injuries, leaks, or
postoperative
strictures.

98.  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.

99. ◦ 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

100. ROLE OF ENDOSCOPIC
DILATATION IN BILIARY
STRICTURES

101.  Adjunctive option in patents with a
dominant extrahepatic stricture
causing clinical symptoms.
 Requires multiple sessions of
dilations
 Nonischemic strictures (anastomotic
strictures) respond best.

102.  Metalic stents are more durable than
plastic stents
 Endoscopic dilation also has a low
mortality rate, but it has a significant
morbidity rate.

103.  Complications following
endoscopic biliary interventions:
◦ Hemobilia
◦ Bile leak
◦ Pancreatitis
◦ Cholangitis
◦ Re-stricture

104. POST-REPAIR COMPLICATIONS

105. 1. Cholangitis
2. Pancreatitis
3. Stent occlusion
4. Stent migration
5. Ductal perforation
6. Restricturing
7. Biliary fistula
8. Hemobilia

106.  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
 Bailay and love 26th e
 Ajay K. Sahajpal et al. Arch Surg.
2010;145(8):757-763.
 de Reuver et al. Ann Surg. 2007;245(5):763-
770.