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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Laparoscopic biliary injury

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Laparoscopic cholecystectomy (LC) has become the gold standard for the treatment of symptomatic cholecystolithiasis. It has a lower mortality and general complication rate than open cholecystectomy. Unfortunately LC appears to be associated with a two to threefold increase in the incidence (0 – 0,9%) and severity of major biliary tract injuries (BTI).

Treatment of BTI is mainly determined by the extent of the injury and the timing of diagnosis. Outcome is determined by the extent of the injury, the timing and quality of treatment.

Mechanism and type of injury

Minor bile leak is defined as being clinically insignificant, whereas major bile leak is defined as resulting in prolonged biliary fistulas, bilomas, abscesses, bile ascites or bile peritonitis.

Injury to the bile ducts can be caused by laceration, transection, excision, clipping, devascularisation or thermal injury. Late stricturing is due to chronic inflammation and fibrosis enhanced by bile irritation.

Small collections in the gallbladder bed are found in about 25% of the patients after cholecystectomy. Half of them contain bile leaking from small bile ducts in the gallbladder fossa. These collections usually have a subclinical course.

Clinical important leakage without interruption of the main extrahepatic bile ducts is most frequently due to cystic stump leaks caused by failure of the clip or partial or complete avulsion due to traction during cholecystectomy. Minor injuries like lateral puncture, incision or laceration are usually caused by instrumental trauma when not dissecting close to the gallbladder neck.

Interruption of the extrahepatic ducts is most frequently due to mistaking the common bile duct for the cystic duct. When this is not recognised in time, it may lead to excision of the bile duct up to the liver hilum with transection of the common hepatic or even both hepatic ducts above the bifurcation. Other less frequent injuries are due to:

  • devascularisation and thermal injury leading to necrosis or stricturing,
  • tenting of the common bile duct due to excessive traction on the gallbladder with partial or complete clipping of the common bile duct,
  • transection or clipping of aberrant right hepatic ducts (mainly from segments VI and VII).

Inflammation (acute or gangrenous cholecystitis), fibrosis, intraoperative hemorrhage and aberrant anatomy are local risk factors for bile duct injuries.


Bile leaks should always be suspected when there is no rapid clinical improvement in the early postoperative period.

One to 2/3 of BTI are not recognized during LC. Intraoperative cholangiography usually does not prevent the BTI to occur, but may help in early recognition and minimizing its severity, when interpreted adequately.

Drainage from a routinely placed gallbladder bed drain can be recognized early and eventually prevent bile peritonitis.

The majority of BTI with leakage are only recognized days to weeks after the initial operation because of abdominal pain or distension, fever, elevated white cell count, abnormal liver function tests and collections seen on US or CT. Early recognition of bile duct injury is crucial in further management.

Treatment BTI at the time of laparoscopic cholecystectomy

Principles of repair are: resection back to healthy viable tissue, tension-free mucosa-to-mucosa anastomosis

When a major BTI is recognized during LC the operation should be converted to a laparotomy. Injuries without interruption of the continuity of the bile ducts can be treated by simple suture repair with (or without) a T tube. Transection or laceration of small aberrant bile ducts can be ligated (clips may slip). When the common bile duct has been clipped, suture ligated or affected by thermal injury, the injured segment is larger due to damage of the microcirculation (dissection, coagulation). The damaged segment should be resected back to healthy viable tissue. Transection of the bile duct is also associated with damage to the microcirculation.

End-to-end anastomoses over a T tube can only be performed when there is limited loss of tissue and no traction on the suture line. Even then the long term failure rate is 40–90%.

When there is tissue loss or traction, the preferred treatment is an end-to-side mucosa-to-mucosa bilioenteric anastomosis to a 50–60 cm long Roux-en-Y jejunal loop. Segmental ducts above the bifurcation can be approximated to each other and sutured to a Roux-en-Y loop.

These anastomoses should be adequately drained to prevent bile collections.

Management of BTI diagnosed after laparoscopic cholecystectomy

These lesions should be treated multidisciplinary (radiology, endoscopy, surgery).Principles of treatment are: drainage of collections, control of bile leak by endoscopic or percutaneous placed drains. If needed, surgical repair should be delayed untill resolution of inflammation.

Major BTI recognized after LC needs a multidisciplinary approach. These patients preferable are sent to specialized hepatobiliary teams.

Work-up is done by ultrasound and CT to diagnose and drain collections. This can usually be done by percutaneous drains. Only diffuse peritonitis or multilocular collections may need surgery. Associated sepsis should be treated by antibiotics. In the absence of bacteriological sensitivity and resistance data piperacilline/tazobactam, ticarcillin/clavulanate or imipenem (or meropenem) are advocated. Endoscopic retrograde cholangiography will confirm the presence of a bile leak and detect residual CBD stones. The ERC will also be therapeutic when there is no interruption of the bile duct, e.g. cystic stump leaks or lateral lacerations. The leak can then be controlled by placement of an endoprosthesis. For these lesions the endoprosthesis is often also the definitive primary treatment.

When the ERC shows a complete transection or obstruction of the distal bile duct, a percutaneous transhepatic cholangiography is essential to define the exact nature and extent of the injury as well as the anatomy of the proximal bile ducts. Percutaneous transhepatic drains should be placed to control the bile leak by complete diversion of the bile flow.

Surgical repair should be delayed until resolution of the inflammation and adhesions associated with biliary leakage.

Hepaticojejunostomy is the preferred method of surgical repair after resection back to healthy tissue.


The outcome of patients with BTI with leakage is determined by the type, level and extent of the injury as well as by the timing, type and appropiateness of the initial treatment.

Leakage without interruption of the continuity of the bile ducts (cystic stump leaks and partial lacerations) usually resolve after endoscopic treatment (endoscopic sphincterotomy, ES with stent or stent alone) with low morbidity and mortality.

Complete transections, excisions and thermal injuries have inferior results when repaired by primary suture with or without T tube. Early or late stricturing are reported in up to 100% of the patients.

Bilioenteric anastomosis using a Roux-en-Y loop is the preferred method of repair and has good to excellent long term results. Results are less good for high level and more complex lesions and after several attempts for repair. Results in expert multidisciplinary hepatobiliary units look better and many studies stress the importance of early referral to these units before any attempt at repair. Published follow-up in most series is short and one should take into account that there remains a life long risk of stricture formation after repair of major BTI.


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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6928


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