Iatrogenic Biliary Injuries: Identification, Classification, and Management

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Key points

  • Laparoscopic bile duct injuries are more complex than those seen in the open era.

  • The unique features of the laparoscopic environment facilitate these injuries; because of this, injuries involving misidentification of the common bile duct (CBD) for the cystic duct are the most common, resulting in a resectional injury of the main CBD and portions of the hepatic duct or ducts.

  • The laparoscopic environment facilitates this illusion, so these injuries are generally not recognized intraoperatively.

Bismuth and Strasberg Classifications

Before the advent of laparoscopic cholecystectomy, biliary strictures were classified using the Bismuth classification (Table 1).12, 13 This useful classification delineated the severity of the biliary stricture based on the level of the biliary injury. The Strasberg classification14 is similar to the Bismuth, but incorporates a few additional biliary injuries seen more commonly in the laparoscopic era (Fig. 1; see Table 1).

Stewart-Way Classification

The Stewart-Way classification incorporates the mechanism of the bile

Intraoperative Bile Duct Injury

A minority of bile duct injuries are recognized during the index cholecystectomy, only about 25% in most series. There are several factors that facilitate recognition of intraoperative injury, but the most important is a change in the surgeon’s awareness to suspect and/or evaluate for a bile duct injury.15 Several features of the gallbladder dissection might indicate the possibility of major bile duct injury. It is fundamental to remember that the CBD lies medial to the gallbladder and that the

Preoperative Evaluation

To guide surgical management, the full extent of the injury has to be defined. This evaluation requires complete cholangiography (as noted earlier). In addition, CT scan with intravenous contrast should be obtained to elucidate any evidence for vascular injuries, hepatic abscess, or presence of hepatic ischemia (generally right-sided if present).

Preoperative Patient Preparation

Before consideration of biliary injury repair, the patient needs to be stabilized and optimized for surgery. Control of intra-abdominal fluid

Summary

Laparoscopic bile duct injuries are more complex than those seen during the open era. The unique features of the laparoscopic environment facilitate these injuries and, because of this, injuries involving misidentification of the CBD for the cystic duct are the most common. This error results in a resectional injury of the main CBD and portions of the hepatic duct or ducts. The laparoscopic environment facilitates this illusion, so these injuries are generally not recognized intraoperatively.

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