Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy

doi:10.1016/j.bpg.2004.05.003

Best Practice & Research Clinical Gastroenterology

Volume 18, Issue 5, October 2004, Pages 829-846

https://doi.org/10.1016/j.bpg.2004.05.003 Get rights and content

Laparoscopic cholecystectomy has become the first choice of management for symptomatic cholecystolithiasis. While it is associated with decreased postoperative morbidity and mortality, bile duct injuries are reported to be more severe and more common (0–2.7%), when compared to open cholecystectomy (0.2–0.5%) [New Engl. J. Med. 234 (1991) 1073; Am. J. Surg. 165 (1993) 9; Surg. Clin. N Am. 80 (2000) 1127]. These bile duct injuries include leaks, strictures, transection and removal of (part of) the duct, with or without vascular damage. Bile duct injury might be due to misidentification of the biliary tract anatomy due to acute cholecystitis, large impacted stones, short cystic duct, anatomical variations, but also due to technical errors leading to bleeding with subsequent clipping and coagulation trauma [Ann. Surg. 237 (2003) 460]. Early recognition and adequate multidisciplinary approach is the cornerstone for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature with as consequences biliary peritonitis, sepsis, abscesses, multiple organ failure, a more difficult (proximal) reconstruction and in the long run, secondary biliary cirrhosis, and liver failure. Despite increasing experience in performing laparoscopic cholecystectomy, the frequency of bile duct injuries has not decreased [Ann. Surg. 234 (2001) 549].

Therapy encompasses endoscopic stenting, percutaneous transhepatic dilatation (PTCD) and surgical reconstruction.

Section snippets

Clinical presentation and diagnosis

Bile duct injuries are recognized in only 11–23% during the index operation.4., 6., 7., 8. Of the remaining 77–89%, in which the injury was not recognized at surgery, the injury was often even not diagnosed during the initial admission.9., 10., 11. The majority of patients with bile duct injuries present initially with only mild or moderate atypical symptoms such as abdominal tenderness, pain or abdominal distension, nausea, vomiting and ileus.12., 13., 14., 15. Early diagnosis is important

Classification of bile duct injuries

A few proposals have been made to classify postoperative strictures¹⁹ and bile duct injuries.4., 6., 8., 20., 21.

The Corlette-Bismuth classification¹⁹, originated from the time of open surgery and is based on the length of the proximal biliary stump (Table 1), but not to the nature and length of the lesion. This classification has a good correlation with the final outcome after surgical repair. A limitation is that patients with limited strictures, isolated occlusion of the right hepatic duct

Types of bile duct injury

Injuries to the bile ducts may range from small postoperative fluid collections containing bile with little or no clinical consequence to total excision of the bifurcation including damage to its vasculature.

In Amsterdam, we developed a modified classification, with direct implications for the further management of the patient.⁸

Management of bile duct injuries

Injuries to the biliary tree during after laparoscopic cholecystectomy, are mostly diagnosed after significant delay.⁴ During laparoscopic cholecystectomy 25–36% of the iatrogenic injuries are recognized.¹³ Also abnormal peroperative cholangiograms are in almost 50% incorrectly interpreted as normal.⁴

Suboptimal evaluation and management of bile duct injuries leads to delayed diagnosis, increased morbidity, and increased severity of the injury, treatment failure and even death.4., 23., 27.

Surgical management

The surgical treatment of bile duct injuries should be separated into treatment of injuries detected during the (laparoscopic) procedure, the early postoperative recognized injury (within a few days after surgery), and finally the delayed detected injuries.51., 52., 53., 54., 55., 56., 57., 58., 59.

Conclusion

Bile duct injuries are a severe complication of laparoscopic cholecystectomy. Early recognition and multi-disciplinary approach will lead to the optimal outcome for the individual patient. For all patients who do not recover immediately after cholecystectomy, and by definition should be suspected of having bile duct injury, we advise to follow the proposed flow diagram as depicted in Figure 7.

Box 1

Box 2

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Cited by (57)

Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis
2023, American Journal of Surgery
Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients.
Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed.
In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17–1.30, p < 0.0001).
Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.
Analysis of surgical errors associated with anatomical variations clinically relevant in general surgery. Review of the literature
2021, Translational Research in Anatomy
Citation Excerpt :
A crucial step in laparoscopic cholecystectomy is adequate assessment of Calot's triangle and familiarity with its associated variations in conjunction with biliary tracts and blood vessels [18–23]. Among the most serious complications of this procedure is damage to the biliary tracts and accompanying vessels [24–27]. The cystic artery (CA) may course anterior to the common hepatic duct or common bile duct, posing a risk of injury to these structures; mistakenly dissecting an accessory CA or deep CA may lead to intraoperative bleeding [22].
Anatomic variations have a significant impact in general and oncological surgery, often necessitating modification of surgical techniques or leading to intraoperative complications. Difficult or variant anatomy is often cited as a significant contributing factor to injuries attributed to surgical errors. In order to investigate the influence of anatomical variations on surgical procedures, a literature search was conducted based on key words and potentially eligible articles were assessed for relevance and quality of data. In this review, we attempt to highlight some major and clinically significant abnormal anatomy that can influence the outcome of a surgical procedure, including cholecystectomy, hepatobiliary, breast and axillary, pancreatic, spleen, gastric, colon, and thyroid surgery, as well as hernia repair.
Treatment of late identified iatrogenic injuries of the right and left hepatic duct after laparoscopic cholecystectomy without transhepatic stent and Witzel drainage: Case report
2018, International Journal of Surgery Case Reports
Citation Excerpt :
Complications of the biliary leak such as cholangitis, bleeding, anastomotic strictures and biliary cirrhosis remain a major concern affecting a patient’s outcome after the surgical operation is done [5]. Bile duct lesions were more common in laparoscopic cholecystectomy, the incidence is about 0.6% than in laparotomy method where the incidence is about 0.1% [6–9]. In most cases, treatment of iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent, or creating duct-enteric anastomosis, often used and drainage by Witzel (Witzel enterostomy).
Most of the case reports about high type iatrogenic hepatic duct injuries reports how to treat and make Roux-en-Y hepaticojejunostomy below the junction of the liver immediately after this condition is recognised during surgical procedure when the injury was made. Hereby we present a case where we made Roux-en-Y hepaticojejunostomy without transhepatic billiary stent and also without Witzel drainage one month after the iatrogenic injury.
A 21-year-old woman suffered from iatrogenic high transectional lesion of both hepatic ducts during laparoscopic cholecystectomy in a local hospital. Iatrogenic injury was not immediately recognized. Ten days later due to patient complaints and large amount of bile in abdominal drain sac, second surgery was performed to evacuate biloma. Symptoms reappeared again, together with bile in abdominal sac, and then patient was sent to our Clinical Center.
After performing additional diagnostics, high type (Class E) of iatrogenic hepatic duct injury was diagnosed. A revision surgical procedure was performed. During the exploration we found high transection lesion of right and left hepatic duct, and we decided to do Roux-en-Y hepaticojejunostomy. We created a part of anastomosis between the jejunum and liver capsule with polydioxanone suture (PDS) 4-0 because of poor quality of the remaining parts of the hepatic ducts. We made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts, without Witzel enterostomy and transhepatic biliary stent. There were no significant postoperative complications. Magnetic resonance cholangiopancreatography (MRCP) was made one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses.
In most cases, treatment iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent or creating duct-enteric anastomosis, often used and drainage by Witzel (Witzel enterostomy). Reconstructive hepaticojejunostomy is recommended for major BDIs during cholecystectomy. Considering that the biliary reconstruction with Roux-en-Y hepatojejunostomy is usually made with transhepatic biliary stent or Witzel enterostomy. What is interesting about this case is that these types of drainages were not made. We tried and managed to avoid such types of drainage and proved that in this way, without those types of drainage, we can successfully do duplex hepaticojejunal anastomoses and that they can survive without complications.
Our case indicates that this approach can be successfully used for surgical repair of iatrogenic lesion of both hepatic ducts.
Chapter 42 - Biliary fistulae and strictures
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
A simultaneous endoscopic and laparoscopic approach for management of early iatrogenic bile duct obstruction
2014, Gastrointestinal Endoscopy
Citation Excerpt :
In the latter setting, the patient usually requires multiple sessions of endoscopic therapy aimed at slow, incremental dilation of the stricture.2,6 Sometimes percutaneous transhepatic cholangiography is required to delineate complete biliary anatomy when the endoscopist is unable to pass a guidewire across the stricture.4,7 Laparoscopy, at present, has no established role in the management algorithm of patients with iatrogenic bile duct injuries.8
Bile duct occlusion secondary to inadvertent application of a surgical clip or suture usually is managed with endoscopic or surgical exploration.
To evaluate the safety and efficacy of a novel method of simultaneous endoscopic and laparoscopic approach in patients with acute iatrogenic bile duct obstruction.
Single arm study and single center design.
University medical center.
Three consecutive patients diagnosed with complete or near-complete obstruction of a bile duct after cholecystectomy were identified for inclusion.
Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopy was performed simultaneously. Surgeon removes the surgical clips or suture from the bile duct with concurrent ERCP by endoscopist to assess and treat bile duct injury following resolution of the block.
Technical and clinical success rate and adverse events.
All of the patients were seen between 5 and 7 days after cholecystectomy. The diagnosis of obstructed bile duct was established by ERCP. The guidewire failed to negotiate across the obstruction in one of these patients. In another patient, a guidewire could be passed, but a biliary stent could not be deployed across the high-grade stricture. In a third patient, only a single biliary stent (7F × 11 cm) could be placed across the obstruction, with significant difficulty. In all the patients, simultaneous ERCP and laparoscopy were performed immediately to remove the surgical clips and/or sutures from the bile duct, followed by placement of biliary stents.
Small series.
The concurrent endoscopic and laparoscopic approach for the management of acute iatrogenic common bile duct obstruction is associated with rapid and complete recovery.
The comparison between endoscopic and surgical treatment of delayed iatrogenic bile duct injury by propensity score matching
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3Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy

Section snippets

Clinical presentation and diagnosis

Classification of bile duct injuries

Types of bile duct injury

Management of bile duct injuries

Surgical management

Conclusion

A prospective analysis of 1518 laparoscopic cholecystectomies

New England Journal of Medicine

Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77.604 cases

American Journal of Surgery

Update on laparoscopic cholecystectomy, including a clinical pathway

Surgical Clinics of North America

Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors a cognitive psychology perspective

Annals of Surgery

Bile duct injury during laparoscopic cholecystectomy; results of a national survey

Annals of Surgery

An analysis of the problem of biliary injury during laparoscopic cholecystectomy

Journal of the American College of Surgeons

Bile duct injuries, 1989–1993: a state-wide experience

Archives of Surgery

Treatment of bile duct lesions after laparoscopic cholecystectomy

Gut

Endoscopic therapy for patients with a post-operative biliary leak

Gastrointestinal Endoscopy

Postsurgical bile leaks: endoscopic obliteration of the transpapillary pressure gradient is enough

American Journal of Gastroenterology

What role can endoscopy play in the management of biliary complications after laparoscopic cholecystectomy?

Endoscopy

Occult biliary injury after laparoscopic cholecystectomy

British Journal of Surgery

Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management

Gastrointestinal Endoscopy

Improvement in the management of bile duct injuries?

Journal of the American College of Surgeons

Laparoscopic surgery: two thirds of injuries initially missed

British Medical Journal

Hilar and intrahepatic biliary enteric anastomosis

Surgical Clinics of North America

Diagnosis of postoperative bile leaks

American Journal of Gastroenterology

Diagnosis of right hepatic duct injury after cholecystectomy: the use of cholangiography through percutaneous drainage catheters

Gastrointestinal Endoscopy

Postoperative strictures of the bile ducts

Characteristics of biliary tract complications during laparoscopic cholecystectomy

American Journal of Surgery

Bile duct injury and bile leakage in laparoscopic cholecystectomy

British Journal of Surgery

Laparoscopic cholecystectomy: evaluation with sonography

Radiology

Bile duct complications after laparoscopic cholecystectomy

Surgical Endoscopy

Surgical significance of the bile duct of Luschka

British Journal of Surgery

Bile duct injury in laparoscopic cholecystectomy

Surgical Laparoscopìc Endoscopy

Bile duct injury following laparoscopic cholecystectomy

American Surgeon

Bile duct injury during cholecystectomy and survival in medicare beneficiaries

Journal of American Medical Association

Laparoscopic injuries to the bile duct

Annals of Surgery

Bile duct injuries during laparoscopic cholecystectomy. Follow up after combined surgical and radiologic management

Annals of Surgery

Advantages and nasobiliary tube drainage in the treatment of cystic duct stump leak complicating laparoscopic cholecystectomy

American Journal of Gastroenterology

The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy

Gastrointestinal Endoscopy

Postoperative bile leakage: endoscopic management

Gut

3
Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy