Surgical Management of CBD Injury Jin Seok Heo Department of Surgery, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Bile duct injury (BDI) Introduction Incidence Prevention (intraoperative cholangiography) Classification Identification Intraoperative postoperative Management Summary
Bile duct injury Major cause of morbidity & mortality following laparoscopic cholecystectomy Major bile duct injury : 0.3%-0.5% Prevention is ideal Early identification & appropriate treatment are critical
Incidence of BDI
Intraoperative cholangiography
Low incidence of BDI No IOC-related complications Facilitated detection and repair during the same surgical procedure with a good outcome.
BJS 2014; 101: 677 684
BJS 2014; 101: 677 684
Classification
Surg Clin N Am 94 (2014) 297 310
Identification of bile duct injury - intraoperative Cholangiographic abnormalities Bile drainage Second cystic artery or large artery posterior to what is perceived to be the cystic duct Identification of an extra bile duct or tubular structure Ductal abnormalities Anomalous anatomy Severe hemorrhage or inflammation
Identification of bile duct injury - postoperative Biliary stricture early recognition with classic presentation (jaundice, dilated bile ducts, abdominal pain) Biliary fistula Most class I and III injury 50% of class II and IV injury mild, relatively nonspecific symptoms including bloating and mild abdominal pain
Identification of bile duct injury - postoperative Any deviation should be recognized as problem CT scan should be obtain Immediate percutaneous drain Complete evaluation for a possible biliary injury
Management Preoperative evaluation Preoperative patient preparation Surgical management principles Specific biliary injury Timing of biliary reconstruction
Preoperative evaluation Define full extent of injury Cholangiography Enhanced CT
Preoperative patient preparation Control of intra-abdominal fluid collections, inflammation, and infection Preoperative nutritional repletion Time to recover from the acute illness
Surgical management principles Eradication of all intra-abdominal infection and inflammation Anastomoses to healthy bile duct tissue Single-layer anastomoses using fine monofilament absorbable suture (Maxon or PDS) Tension-free anastomoses Roux-en-Y hepaticojejunostomy, in most cases Experienced biliary surgeon
Specific biliary injury
Cystic duct leak ERCP, stenting and drainage of intraabdominal bile collections
Class I injuries Simple suture using fine monofilament absorbable suture ( no need T-tube)
Other than Class I -Immediate reconstruction -Refer to biliary specialist
Class IV injuries Class IV injuries that do not include transection of the duct - managed nonoperatively Class IV injuries involving transection of the bile ducts - reconstruction of the duct into a defunctionalized Roux limb.
Vasculobiliary injury Definition - an injury to both a bile duct and a hepatic artery and/or portal vein Right hepatic artery (RHA) vasculobiliary injury (VBI) - the most common variant Slow hepatic infarction in about 10% of patients Repair of the artery - rarely possible and the overall benefit unclear Injuries involving the portal vein or common or proper hepatic arteries - much less common, but have more serious effects
Timing of biliary reconstruction
Summary Early recognition Control of intra-abdominal bile ascites and inflammation Nutritional repletion repair by a surgeon with expertise in biliary reconstruction
Summary Endoscopic management should be the first line treatment in the absence of complete circumferential transsection of the main bile duct. In case of complete circumferential bile duct injury, hepatico-jejunostomy is essential for optimal healing.