Page 18 - World Journal of Laparoscopic Surgery

Common Bile Duct Injuries During Laparoscopic Cholecystectomy

6. The surgeon should limit the use of all energy sources and percutaneous or endoscopic techniques depending on
prefer pledged dissection near the CBD and recognized that length of stenosis or if.
they can cause occult injury.
7. Use suction and irrigation frequently. Classification of Biliary Duct Injuries
8. The surgeon should not hesitate to convert to an open
operation for technical difficulties, anatomy uncertainties If complication recognized intraoperatively:
or anatomical anomalies. 1. For high complete transaction Roux-en-y hepatojejuno-
9. The surgeon need to see all structure clearly before dividing stomy.
any ductal structure. 2. For lower complete injuries – Primary suture repair over T
10. Peroperative cholangioraphy may be a little helpful to avoid tube.
bill duct injury, but it is quite helpful to diagnose bill duct 3. Long end of T-Tube most not be exteriorized from same
injury at the same time allowing first appropriate treatment side for partial injuries insertion of T-tube and Roux-en-y
at the same time. serosal patch.
11. Surgeon should prefer extracorporeal knotting as mass Strategy to handle complication recognized postoperatively
legation just below the GB. Ultrasound + ERCP + MRCP + PTC.
12. Neck in cases of difficult dissection of cyst duct and artery. After the detecting the injury or other complication due to
bile duct injury, after resuscitation the patient, is treated with
BILE DUCT fluid + electrolytes + systemic antibiotic.
Patient should be reffered to appropriate center like:
Biliary tree is the whole network of various size ducts branching secondary or tertiary center for further management accordingly
through liver path is as follows: The principal of treatment is to re-establish a pressure gradient
Bilicalculi – Canals of hering – Interlobular bile duct – Intra- that will favour the follow of bile into the duodenum not outside
hepatic bile duct – Right and left hepatic bile duct merge to form the leak side like:
– Common hepatic duct and join cystic duct form – Common 1. Conservative treatment and billiary drainage for 6 weeks by
bile duct (join pancreatic duct) form ampulla of vater and enters ERCP stent- insertion.
the second part of duodenum. Or PTBD if endoscopic stent application is not possible.

The Bismuth classification for bile duct injury is: 2. Some times internal stenting with or without sphincterotomy
Type I – CHD stump > 2 cm. is effective in treatment of small leaks.
Type II – CHD stump < 2 cm. 3. A retrospective study by De Palana, et al in 2002 showed
that sphincterotomy alone was highly effective in producing
Type III – Hilar right and left duct injury with confluence intact.
closure of bile fistulas by reducing endobilliary pressure.
Type IV – Hilar separation of right and left duct. 4. After several weeks, reconstative surgery like Roux-en-y
Type V – Injury to aberrant right duct ± CBD injury. cholecystectomy or hepato jejunostomy should be
In 1995 Strasberg and Soper modified the Bismuth performed if necessary.
classification of bile duct injury.
1. Type A – Bile leak from a minor duct still in continuity with CONCLUSION
the common bile duct.
These leaks occur at the cystic duct or from the liver bed. The principal difference form surgeon’s perspective between
2. Type B – Occlusion of part of the biliary tree. Usually the laparoscopy and open cholecystectomy is the lack of three
result of an injury to an aberrant right hepatic duct. In 2% of dimensional views of structures to be manipulated. During
patients, the cystic duct enters a right hepatic duct rather laparoscopy procedure a surgeon is guided by a two dimensional
than the common bile duct–Common hepatic duct junction. image seen on a television and screen depth perception is
The aberrant duct may be a segmental duct, a sectoral duct affected. That required higher level of coordination and
(the right anterior or posterior duct), or even patience. After diagnosing the CBD injury during operation it
3. Type C – Bile leak from duct not in communication with should be repaired with appropriate method either open or
common bile duct. laparoscopically. If diagnosed in postoperative period then it
Usually diagnosed in early postoperative period as an should be always managed in secondary or tertiarycenter with
intraperitoneal bile collection. the operate methods with fully skilled surgeon. Inspite of a little
4. Type D – Lateral injury to extrahepatic bile ducts. May more risk of bile duct injury. Laparoscopic cholecystectomy is
involve the common bile duct, common hepatic duct, or the still the gold standard of method for GB stone diseases due to
right or left bile duct. other benefits over open cholecystectomy. After taking care of
5. Type E – Circumferential injury of major bile ducts. This possibilities of CBD injury, early diagnosis and proper
type of injury causes separation of hepatic parenchyma management, laparoscopic cholecystectomy is still the gold
from the lower ducts and duodenum. May be treated by standard for GB stone diseases.
World Journal of Laparoscopic Surgery, September-December 2009;2(3):15-18 17