Injuries to the bile duct that are almost universally iatrogenic and may infrequently be due to trauma. The most common procedure causing a bile duct injury is the laparoscopic cholecystectomy. Historically the incidence of bile duct injury while performing an open cholecystectomy was as low as 0.1% to 0.2%, but with the introduction of laparoscopic cholecystectomy, the incidence has increased to 0.4% to 0.6% of patients. Any major bile duct injury may result in significant morbidity, increased mortality, and financial burden on the patient. These injuries should be prevented with meticulous technique and selective use of intra-operative cholangiography. The most common technique to repair major bile duct injuries is the Roux-en-Y hepaticojejunostomy (RYHJ).
Biliary anatomy and its vascular supply can be variable, which may lead to inadvertent injury or confusion during reconstruction.
Normal Biliary Anatomy
Extra-hepatic right and left hepatic bile ducts join at the hilar plate anterior to the right portal vein to form the common hepatic duct (1 to 4 cm long and approximately 4 mm in diameter), which becomes the common bile duct (7 to 11 cm long and 5 to 10 mm in diameter) after giving off the cystic duct to the gallbladder. The common bile duct enters the second portion of the duodenum through the sphincter of Oddi (a muscular structure which controls the flow of bile into the duodenum).
The common bile duct most commonly joins the main pancreatic duct outside the duodenal wall and traverses it as a single duct.
Cystic Duct Anatomy
Variations occur in as many as 40% of patients, and it is important to recognize these as they may predispose a surgeon to a bile duct injury. Important variations include the cystic duct circling anterior or posterior to the common hepatic duct prior to its insertion (occurs in 5% of patients), cystic duct draining into a right posterior hepatic duct (occurs in 0.6% to 2.3% of patients), and accessory ducts of Luschka (occurs in 15 to 30% of patients).
Right Hepatic Ductal System
Normal anatomy is present in 57% of patients. The right hepatic duct is a union of the right anterior and posterior sectoral ducts in normal patients. Common variations include drainage of the right posterior sectoral duct into the left hepatic duct (occurs in 20% of patients); drainage of the right anterior sectoral duct into the left hepatic duct (occurs in 6% of patients); and low insertion of the right hepatic or right sectoral duct into the common hepatic or cystic duct (known to increase iatrogenic risk of common bile duct injury during laparoscopic cholecystectomy).
Left Hepatic Ductal System
Normal anatomy is present in 67% of the population and is described as the junction of the left lateral and medial sectoral ducts to form the left hepatic duct.
Biliary Blood Supply
The blood supply to the common bile duct and the common hepatic duct is provided by 2 small arteries that travel along the lateral borders of the ducts at the 9 and 3 o'clock positions. These are branches of the right hepatic and cystic arteries superiorly and the posterior superior pancreaticoduodenal and gastroduodenal arteries inferiorly. The 2 arteries unite and form a plexus on the surface of the bile ducts. The supra-duodenal common bile duct is the most prone to ischemia due to the relatively poor blood supply when compared to the distal common bile duct. Arterial variants are common, and consist of a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery.
The indications for bile duct repair are dependent on the mechanism, temporal recognition, and classification of the injury. Depending on the type of injury and when it is recognized will determine if and when an operation is required.
This is the most common system used (Type A to E; E1 to E5)
Timing of Recognition (determines management)
Intraoperative recognition should typically prompt immediate surgical repair as this confers the best outcomes; however, less than 40% of bile duct injuries are recognized at the index operation. Stewart and Law reviewed bile duct repairs done by specialists and general surgeons and found that only 17% of patient repaired by the general surgeon had a favorable outcome. Bile duct injuries should not be underestimated. If the surgeon is inexperienced, an intraabdominal drain should be placed, and the patient should be immediately transferred to a hepatobiliary specialist.
Procedure recommended for specific injuries requiring operative repair:
Absolute contraindications for an RYHJ are the same for other surgical procedures: the inability to tolerate general anesthesia. An intrahepatic proximal bile flow obstruction is also a contraindication to an HJ.
Relative contraindications include timing of operation in the early postoperative period and uncontrolled biliary sepsis.
Standard laparotomy surgical equipment is required.
Specific for HJ:
As a delayed biliary injury the biliary tree will have been thoroughly investigated with various modalities of cholangiography. The patient will have been treated for sepsis, bile leak, and biliary obstruction with antibiotics, IR-guided drainage or PTC/ERCP with biliary stenting and drainage. For high common duct injuries, percutaneous stents placed in the proximal injured bile ducts is a valuable tool for identification intraoperatively.
Perioperative mortality is reported to be 1.7%, and morbidity is 43%.
The most common early complications are bile leak (5%), intraabdominal abscess (3%), wound infections (8%) and cholangitis (6%). Very few of these patients require intervention and if they do it is by percutaneous means.
Late complications are primarily comprised of anastomotic stricture formation and recurrent cholangitis which with advancing techniques is highly responsive to endoscopic ballooning and stenting.
Many major bile duct injuries will require surgical repair. There are many described techniques for complex biliary injury repairs including primary repair or primary end to end anastomosis of bile ducts, choledochoduodenostomy, and cholecystojejunostomy. The most popular surgical repair is the Roux-en-Y hepaticojejunostomy. This operation has been consistently superior to the other methods when considering long-term outcomes. There are many different techniques described to perform an RYHJ, and the operating surgeon should choose the method with which he or she is most comfortable or experienced.
Iatrogenic biliary tract injury is a rare but devastating complication of the commonly performed laparoscopic cholecystectomy in the modern age. The extent of injury can range from mild to severe, and treatments vary accordingly to the injury. Management of bile duct injuries has 3 main goals: control of sepsis, defining and classifying biliary anatomy/injury, and definitive repair of the injury. The bile duct injury is primarily managed by a multidisciplinary team that includes a surgeon, radiologist, gastroenterologist, infection disease consultant, and an intensivist. These patients usually require close monitoring in an ICU setting by critical care nurses and pharmacist for appropriate pain control. Repair of bile duct injury is also associated with significant complications that include an anastomotic leak, abdominal abscess, liver failure, wound infections and cholangitis. The mortality rates depend on the type of injury and comorbidity but can range as high as 20-40%.(Level V)
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