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1. Risk of biliary tract injury during laparoscopic surgery By
Dr Fadhl Ali Almohtady
2. INTRODUCTION Open cholecystectomy was the standard practice for treartment of symptomatic gallbladder disease until later 1980
At present more than 90% of cholecystectomies are performed by laparoscopy which become one of the commonest surgical procedure in the world.
Unfortunately the widespread used of laparoscopy has lead to a concurrence rise in the incidence of major bile duct injury(BDI)
3. Complications of Laparoscopic Cholecystectomy :A National Survey of 4,292 Hospitals and an Analysis of 77,604 Cases 1.750 respondents
1.2% laparotomy for treatment of complications
0.6% mean rate of bile duct injury (exclusive of cystic duct), that will be lowered after performing > 100 LC
50% of bile duct injury was recognized postoperatively, required anastomotic repair
33 pts died, 18 of them due to operative injury
0.14% bowel injuries
0.25% vascular injuries
4. Biliary injury during cholecystectomy OC :has been associated with 0.2%-0.4% risk of BDI.
ON THE OTHER HAND (LC): has been associated with 2.5 fold to 4 folds increase in the incidence of post operative BDI.
in 1990 high rate of BDI is due to in part to learning curve effect .
A surgeon had i.7% chance of BDI in the first case a 0.17% chance of BDI after the 50th case.
However,most surgeon passed through the learning curve (steady state)
5. BILE DUCT INJURY (I) Any injury to the bile duct during cholecystectomy is a dreaded complication.
Major bile duct injuries may require biliary-enteric reconstruction
Many patients, their consultants, and their lawyers believe these treatments result in a lifetime of disability
(Maraca R.J et al : Arch Surge 2003, 137:889-894)
6. BILE DUCT INJURY (2) The occurrence of an accidental bile duct injury strikes the patient and surgeons with great force, as neither is prepared for this complication
Often the surgeons is not immediately aware of disaster, and a delayed diagnosis adds further difficulty to the potentially disturbed relationship between doctor and patient.
(Gouma DJ and Obertrop H : BJS 2002,89,385-386)
7. The Problem LC has been associated with a higher incidence of IA bile duct injuries
LC0.4 to 0.8%
Increased mortality and morbidity
Reduced long-term survival
Reduced quality of life
Between 34% and 49% of surgeons are expected to cause such an injury during their career.
Awareness and preventative methods are of clinical importance to surgeons.
8. Risk Factors and Mechanism Risk Factors
Surgeon related risk factors
Lack of experience
Misidentification of biliary anatomy
Over confidant surgeon
Improper iterpretation of ioc
Improper lateral retraction (insufficient or excess
Lack of conversion into OC in difficult cases
9. Risk Factors.cont Patient related risk factors:
Age & sex
Anatomical variations (biliary and vasculature)
Severity of disease : Acute ,chronic cholecystitis,empyema and mirizzi syndrome,..
previous surgery with adhesions.
11. Common Variant's of bile duct anatomy
12. MANNER OF CONFLUENCE RIGHT SECTORAL DUCTS Blumgart LH. Surg Clin N Am. 1994.74.4
13. Risk Factors.cont Risk factors inherent to laparoscopic approach;
2-dimensional video monitor view, fixed view point, etc
.loss of depth perception
Lack of manual palpation
Surgeon dependant to equipment
Blind manipulation the instruments
14. Mechanism of injury
InitiallySurgeons Learning Curve Steady
Anatomical Misidentification: excision, incision, or transection of biliary anatomy
Injuries: common bile duct, common hepatic duct, right and left hepatic ducts, right hepatic artery, ducts draining hepatic segments
Anatomical variations (biliary and vasculature)
Electro cautery, thermal injury: stricture of CBD or hepatic ducts, bile leak
Mechanical trauma: stricture of the biliary ducts, bile leaks
Improper surgical approach
15. Misidentification injuries 2 main types ;
1-CBD is mistaken for cystic duct so is clipped and divided.
2-The segment of an aberrant right hepatic duct at the junction of cystic duct and CHD is mistaken for cystic duct
16. Classic Laparoscopic Injury --Mistaking the common bile duct for the cystic duct
18. Thermal Injuries Inappropriate use of electro cautery near biliary ducts
May lead to stricture and/or bile leaks
Mechanical trauma can have similar effects
20. CHD DRAINS FREELY IN TO THE PERITONEAL CAVITY Lacey Clinic, Burlington, MA 1994
21. CLASSIFICATION OF BDI There are many classification systems,
Bismuth ,McMahon, Strasberg, Amesterdam academic medical center;s classification, Stewart and so and so..
22. CLASSIFICATION OF BDI..cont PURPOSE to know the severity of the injury.
Communication purposes between doctors and centers
Treatment purposes modality of treatment
23. Bismuth's classification (1982)[ Type Criteria
1 Low CHD stricture, with a length of the common hepatic
duct stump of >2 cm
2 Proximal CHD stricture-hepatic duct stump <2 cm
3 Hilar stricture, no residual CHD, but the hepatic ductal
confluence is preserved
4 Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct
5 Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the CHD.
24. Bile Duct Injuries
26. McMAHON classification TYPE OF INJURY CRITERIA 1-MAJOR BDI
2-MINOR BDI 1-Laceration > 25% of bile duct diameter.
2-Trasection of CHDor CBD.
3-Development of post-operative sticture.
1-Laceration of<25% of BD diameter.
2-Laceration of cystic-CBD junction(buttonhole tear)
27. Strasberg Classification Type A Cystic duct leaks or leaks from small ducts in the liver bed
Type B Occlusion of a part of the biliary tree, almost invariably the
aberrant right hepatic ducts
Type C Transection without ligation of the aberrant right hepatic
Type D Lateral injuries to major bile ducts
Type E Subdivided as per Bismuth classification into E1 to E5
28. Strasberg Classification, contd E: injury to main duct (Bismuth)
E1: Transection >2cm from confluence
E2: Transection <2cm from confluence
E3: Transection in hilum
E4: Separation of major ducts in hilum
E5: Type C plus injury in hilum
31. AMESTERDAM ACADEMIC MEDICAL CENTER 4 TYPES OF BDI CAN BE IDENTIFIED (MCMOHAN)
TYPE A:cystic duct leak or leakage from a berrant or peripheral hepatic radicles.
TYPE B:major bile duct injury with or without concomitant biliary stricture.
TYPE C:bile duct sticture without biliary leakage.
TYPE D:complete transection of BD with or without excision a part of the duct.
32. . Stewart-way classification of BDI (2004) ]
? CBD mistaken for cystic duct, but recognized
Cholangiogram incision in cystic duct extend
? Bleeding, poor visibility Multiple clips placed on CBD/CHD
? CBD mistaken for cystic duct, not recognized
CBD, CHD, or right or left hepatic ducts transected and/or
? Right hepatic duct (or right sectorial duct) mistaken for
Right hepatic artery mistaken for cystic artery
Right hepatic duct (or right sectorial duct) and right
hepatic artery transected
33. Way LW et al: An Surge, vole 237 No.4. 460-465, 2003
34. BUT NON OF THESE CLASSIFICATION SYSTEM IS UNIVERSALLY ACCEPTED AS EACH HAS ITS OWN LIMITATION
35. About 25% of BDI discovered intra-operatively.
About 25% of BDI discovered after 24-48 hs post-operatively.
And about 50% of BDI present weeks ,months or years post operatively
36. CLINICAL PRESENTATION Many injuries are unrecognizedd at the time of the initial operation, and their presentation will vary
Those with associated bile leak will present early and often acutely ill from bile peritonitis or sub-hepatic abscess
37. CLINICAL PRESENTAION.CONT Those with an injury but not leak, usually develop jaundice sometime after discharge from hospital, depending of the nature of the injury
Some injuries evolve slowly or cause partial obstruction
Stricture may involve principally the right or left hepatic duct or one of the right sectorial hepatic ducts
38. BILE LEAK IS RECOGNIZED EARLIER Presentation:
39. Intraoperative Detection Only 25% of injures are recognized intraoperatively
If experienced, convert to Open Procedure and perform Cholangiography (determine extent of injury)
If not experienced, perform the cholangiogram laparoscopically with intent of referring patient (placement of drains)
Consult an experienced hepatobiliary surgeon.
Quicker the repair, the better the outcome!!!
40. Post-Operative Detection Plan Controlling sepsis, establish biliary drainage,
No need for urgent reconstruction of the biliary tree.
Reconstruction of the biliary tract is best performed electively after an interval of at least 6 to 8 weeks.
41. TIPS & TRICKS TO DIAGNOSE BILE DUCT INJURY History of unexplained fevers, pain, abnormal liver function test results, or pruritus
Should prompt an investigation
42. TYPES OF IMAGING INVESTIGATION Ultrasonography :
May reveal the :
ductal dilatation and or fluid collection(biloma
Of little value if bile ducts are decompressed
43. TYPES OF IMAGING INVESTIGATION (2) Cholangiography
PTC is superior to ERCP
MRCP : Noninvasive, provides striking images of biliary tree
HIDA scan ; may show presence of active bile leak and general anatomic site of leakage.
44. MRC ;
Demonstrating dilatation or stenosis of the biliary tract; and stones in the bile duct remnant; the pancreas; and pancreatic duct;
However it doesnt allow concomitant therapeutic measures.
45. ERCP; PTC
Can provide an exact anatomical diagnosis of bile duct leak.
Allowing for treatment of the leak by appropriate decompression of the biliary tract
46. TYPES OF IMAGING INVESTIGATION Contrast-enhanced CT
The best initial study
May define level of injury, fluid collection or ascites
Reveal lobar atrophy
For vascular injury; CT angiography, MR -angiography
50. RIGHT LOBE ATROPHY AND COMPENSATORY LEFT LOBE HYPERTROPHY
51. Can BDIs be prevented?
52. Conclusions Bile duct injury during cholecystectomy, either laparoscopic or open, is a complex and a dreaded complication
The proximal bile duct is at greater risk for injury in laparoscopic surgery and may require biliary-enteric reconstruction
Early recognition, good surgical technique;
adequate multidisciplinary approach in a tertiary care center are the cornerstones for good outtcome.
53. Thank you