laparoscopic bile duct injury mechanism of injury prevention and management

2. Bile Duct Injuries
Prevention & Management
Dr.S.Easwaramoorthy
MS FRCS(Eng) FRCS (Glas) FRCS (Edin)
Head of Dept of Minimal Access Surgery
Lotus hospital, Erode
Examiner, RCS of Edinburgh
Executive Member, South Zone IAGES

3. World’s First Lap Chole
Phillipe Mouret-1987
Erich Muhe-
1985
They made it feasible, let us make is safe!....

4. Risk of Bile Duct Injury
•More Often
•Happens in 0.5% cases
•Major injury
•More proximal ducts
1.6 million Lap chole in Medicare beneficiaries-1992-1999
Lap Chole is the answer,
but…
Learning Curve Vs Real Danger

5. Why more BDI?
Upward retraction of fundus

6. So What?
1. Upward retraction of fundus
2. Down and out retraction of Hartmann’s
Assistant’s Left hand in Open Chole
Surgeon’s Left hand in Lap chole

7. Visual Perceptual Illusion
You see What U want to See

8. Pathogenesis of Bile Duct Injury I
Misidentification of Bile duct as cystic duct
Classical BDI during Lap Chole
Disaster
Dangerous Anatomy
Dangerous Pathology
Bile duct is cut twice to remove the GB

9. Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury

10. Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury

11. Pathogenesis of Bile Duct Injury II
Dangerous Technique!!
1. Dissection Injury
2. Traction injury
3. Diathermy Injury

13. 1.Trouble Prevention I
1. Follow the Steps of Safe Cholecystectomy
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View
1. Look for Cues of bile duct injury
2. Cholangiogram

14. 1.Identify Junction of Cystic duct and GB
Infundubular Technique
Elephant Trunk Sign
99% Cholecystectomy is better than
101% cholecystectomy!
Beware: Hidden cystic duct syndrome

15. 2.Rouviere’s Sulcus
Extra biliary reference point for safe navigation!

16. Are we One Hundred Percent Sure?!
3.Strasburg’s Critical View of Safety

17. Trouble Prevention II
1. Steps to avoid bile duct injury
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View of Safety
1. Look for Cues of bile duct injury

18. Red Flag Signs of BDI
• Unclear Anatomy/Anomaly
• Dangerous pathology
– Acute Cholecystitis
– Mirrizi’s Syndrome
– Impacted stone at Cystic duct
– Large stone in Hartmann’s pouch
• Clips are small for the duct!
• Unexplained bile leak!!
• Unusual field of vision
– More Duodenum, Less Liver
Golden
yellow

19. Trouble Prevention III
1. Steps to avoid bile duct injury
– Identify GB-Cystic duct junction
• Elephant Trunk sign
– Rouviere’s Sulcus
– Critical View
1. Look for Cues of bile duct injury
2. Cholangiogram

20. When in doubt,
Consider Cholangiogram
Indication
Unclear Anatomy
Suspected Bile duct stone
May not prevent BDI but could aid its early recognition!

22. 2.Trouble Management
• How to recognize BDI?
• What Investigations?
• When to intervene?
• Which repair?
Classical BDI during Lap Chole

23. 1.How to recognize BDI
• Intra operatively(25%)
– Don’t panic!
– Drain/Control of sepsis
– Refer
• Post operatively
– Pain
– Bile leak
• Pain, Bile in the drain, signs of peritonism
– Biliary Obstruction
• Abnormal LFT, Jaundice, cholangitis

24. 2.Role of Imaging in BDI
1. US/CT abdomen
– To look for any collection/ Guided drainage
1. HIDA scan
– Confirms leak but fail to give anatomic detail we need
1. PTC
– To visualize the proximal ducts and assess the grade the injury
– Stenting?
1. MRCP
– Non invasive Test of Choice to assess the grade of injury
– Both proximal and distal ducts could be seen and leaks also could
be identified
1. ERCP
– Mainly delineate distal ducts only
– Mainly for Therapeutic purpose /operator dependent

25. 3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic
ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
US/CT Guided Drainage
ERCP and Stenting
A D
Bilioma is prone for infection and bile can destroy
tissues, so act quick!

26. MRCP & then ERCP
ERCP/Sphincterotomy/Stenting

27. 3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic
ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
B Rare

28. 3.Trouble Management
Type Strasburg Classification of BDI
A Cystic duct leaks or leaks from small ducts in the liver bed
B Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts
C Transection without ligation of the aberrant right hepatic duct
D Lateral injuries to major bile ducts
E Subdivided as per Bismuth’s classification into E1 to E5
C
Rare

29. Types of Major Bile Duct Injuries
Typ
e E
Bismuth Classification of Bile Duct Stricture
1 Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm
2 Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm
3 Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved
4 Hilar stricture, with involvement of confluence and loss of communication between right and left
hepatic duct
5 Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the
common hepatic duct
E 1 & 2 E3 E5E4

30. MRCP & ERCP in BDI
35 yr lady with classical post lap chole
MRCP can see both above and below
the level of biliary obstruction
So no need for PTC! Excision injury of bile duct

31. 4.Which repair & When?
• Hepaticojejunostomy
– Let us leave it to the experts…
– 1st
time is the best
– <72 hr or wait till 6 weeks
• End to end repair over T tube: seldom done
Bile duct injuries associated with Lap chole.
Timing of repair and long term outcome
Arch Surgery 2010 : 145 (8): 757-763

32. Hepatico jejunostomy-1

33. Hepatico jejunostomy-2
Tension-free and widely patent,
with a mucosa-to-mucosa anastomosis.
Ensure well-vascularized bile ducts and
use monofilament absorbable sutures

34. Conclusion
• Let us adhere to safety rules of Lap chole
• Bile duct injuries are disastrous
• Management of BDI needs Specialist