Management of Bile Duct Injury Detected Intraoperatively

Abstract

A bile duct injury is detected during laparoscopic cholecystectomy in only about one-fourth to one-third of the cases in which it occurs; in the remaining cases, it manifests in the postoperative period as bile leak or during the follow-up as a benign biliary stricture. If bile is seen during laparoscopic cholecystectomy, the surgeon should stop any further dissection. If a bile duct injury is suspected, the operating surgeon, who is likely to be a general (non-biliary) surgeon, should not attempt to repair the injury; only lavage and subhepatic drainage should be performed and the patient should then be referred to a biliary center for further management. A small lateral injury to the common bile duct may be suture repaired laparoscopically by a skilled laparoscopic surgeon. In case of a complete common bile duct injury, the injury may be repaired after conversion to open operation but only if help of a biliary surgeon is available. If there is no loss of segment of bile duct, an end-to-end repair may be performed (though with a higher risk of restricture). If a segment of the bile duct has been excised, hepatico-jejunostomy is the only option. Results of immediate (intraoperative) repair, even in the hands of biliary surgeons, are, however inferior, to those of delayed repair.

Also see Invited Commentary on Management of Bile Duct Injury Detected Intra-operatively by Keith D Lillemoe (pp 105–106)

Invited Commentary on Management of Bile Duct Injury Detected Intraoperatively

• Keith D. Lillemoe 

1. Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

   Keith D. Lillemoe

The chapter by Professor Kapoor is a well written summary defining the strategies and outcomes used by surgeons in the management of a bile duct injury (BDI) detected intraoperatively during cholecystectomy. As the Author (VKK) clearly documents, intraoperative detection of BDI during a laparoscopic cholecystectomy still occurs in less than 50% of the cases, therefore eliminating this important option in the management of most patients. Yet, as Professor Kapoor points out, recognition does not necessarily lead to the correct decision-making or best outcomes.

I personally agree with essentially every strategy that Professor Kapoor puts forth in this chapter. The most important message that I might add is that once an injury has occurred during a laparoscopic cholecystectomy, the operating surgeon’s goal is to do no further harm. The reasoning behind this important tenet is that in most cases the cholecystectomy resulting in a BDI is not being performed by an experienced biliary surgeon. Thus, not only is emotion and judgment altered by the event, but experience is often lacking. If, however, the situation exists where an experienced biliary surgeon is available, he or she should be brought to the Operating Room immediately to assist in the decision-making, delineation of the anatomy, and the reconstruction.

The best time to repair any BDI injury is at the time that it occurs. Such treatment decreases postoperative complications, stress to the patient (which often leads to lawsuits), and lowers the costs of care associated with subsequent admissions and procedures. Nevertheless, a “botched repair” not only results in an unsuccessful outcome but more often than not it creates a worse situation with respect to the technical repair of the injury. Thus, the messages from this chapter as to optimal management are very important.

I also agree with all the points that Professor Kapoor puts forth concerning end-to-end repair of a bile duct injury. Although this technique has a high incidence of failure with late stricture, such strictures do allow the biliary endoscopist an opportunity to dilate the stricture without the need for surgery or percutaneous intervention.

I would agree with Professor Kapoor that if a repair is not to be completed, minimizing the complications of the injury by controlling the bile leak is the most important step. The bile duct should not be clipped in order to control the bile leak or to theoretically allow the proximal bile ducts to dilate, in that this action seldom results in the desired outcome in either case and often results in loss of ductal length for ultimate repair.

Finally, the only point that I might add to this excellent review by Professor Kapoor relates to the role of transanastomotic stents to decompress the biliary system after biliary enteric reconstruction. Such stents are placed in a transhepatic fashion in cases when a hepatico-jejunostomy is performed and allows decompression of the biliary tree in cases when an anastomotic leak occurs, allows access for postoperative cholangiography to assess the repair, and allows access for percutaneous intervention such as balloon dilation, if necessary. The technique for placing these stents, as described by the group from the Johns Hopkins Hospital, Baltimore, MD, USA is relatively simple and seldom is associated with additional morbidity or difficulty with reconstruction.

I enjoyed this well written chapter and feel that it is the principles put forth by Prof Kapoor which should be understood by any surgeon performing laparoscopic cholecystectomy. Even with the relative infrequent nature of these injuries, it is important that the surgeon performing laparoscopic cholecystectomy knows what to do in this setting. If, however they do not know anything more, the most important word of advice is to call someone locally or at a nearby academic center for either consultation and/or assistance should a bile duct injury occur.