*8.1.1 Diagnosis of biliary injury*

Minor BDI are associated with partial lesions without tissue and continuity loss. Major BDI are associated with tissue loss or interruption or occlusion of the main hepatic duct. In a situation when BDI is recognised during laparoscopic surgery,

**Figure 10.** *Schematic image of transected CHD (Type E, Bismuth Type II).*

#### **Figure 11.**

*Schematic image of transected CHD in the confluence (Type E, Bismuth Type III).*

conversion to an open procedure and attempt for a repair is recommended only when the surgeon is skilled in advanced biliary surgery. Non-expert immediate attempts for repair are associated with worse outcomes, and they can compromise later revisions; therefore, an intraoperative consultation of an expert is recommended and patients especially with major BDI should be referred to a hepatobiliary centres with multidisciplinary care [39, 41]. External drainage of the subhepatic space is recommended, and a patient should be referred to the centre early because delayed transfers are associated with a higher rate of complications [42].

In case of intraoperative suspicion of BDI or when patients' biliary anatomy is unclear, intraoperative cholangiography may be helpful [28]. Currently, it is not generally recommended to perform routine intraoperative cholangiography because it is not associated with a significant reduction of BDI rates and it can lead to BDI itself because of misinterpretation of patients' anatomy.

#### **Figure 12.**

*Schematic image of separated major duct from the right and left hepatic duct (Type E, Bismuth Type IV).*

#### **Figure 13.**

*Schematic image of interrupted aberrant right hepatic duct (Type C) combined with the injury in the hilum (Type E, Bismuth Type V).*

#### **8.2 Bile leaks**

This group represents biliary injuries types A, C, D, and E.

Type A leak is localised from the cystic duct or the bile duct Luschka [43]. It can be caused by loosen ligature or dislodged clips because of a frail tissue or obstruction of the cystic duct remnant.

Bile duct of Luschka is a minor accessory bile duct that directly enters the gallbladder in the bed. Clinically, significant leakage from the duct after cholecystectomy is not very common.

Types C and D leaks are related to BDI to aberrant and main ducts.

Clinical presentation depends on the extent of the lesion. Minor lesions with small perihepatic collections may remain asymptomatic for a long time or may resolve spontaneously. Major lesions are followed by massive biliary leakage and affected patients are usually symptomatic. Typical symptoms are abdominal pain, bilious collections or bilious ascites, fever. In this case, jaundice is a variable sign because the

serum level of bilirubin can be just slightly elevated. Leucocytosis and elevated serum levels of alkaline phosphatase and gamma-glutamyl transferase are common [39].

If subhepatic drainage during cholecystectomy is performed, bile leakage is usually obvious and the extent of the lesion can be indirectly estimated.

#### *8.2.1 Radiologic examinations and management*

Transabdominal ultrasonography (US) is the basic examination that can describe perihepatic fluid collections and the biliary tree diameter. If the US finding is unclear and the symptomatology is worsening, the CT may be helpful to detect free intraperitoneal fluid or associated vascular injury (triphasic CT) [44].

Large collections or free peritoneal fluid of larger volume can be percutaneously drained and examined for assessment of bilirubin levels. It is recommended to take a sample for microbiological examination and in case of clinical and laboratory proof of sepsis development (elevated inflammatory markers), empiric antibiotic treatment is reasonable, particularly in patients with a history of biliary infections and preoperative ERCP and stenting [44].

Bile leakage can be verified by biliary scintigraphy with hepatobiliary iminodiacetic acid scan (HIDA). It is very sensitive in the diagnosis of an ongoing bile leak, though it cannot anatomically localise the site of the leakage. Major leaks can be obvious on early scans, but if early scans are negative, delayed scans after 3 h from tracer injection are recommended [45].

MRCP is a non-invasive method that can be used for the diagnosis of bile leak and localisation of the leak site. It is particularly important in the case of hilar injury [46].

ERCP is an examination that can determine the side of the BDI and offers a possibility of the insertion of the biliary stents. Stenting across the ampulla can solve the majority of BDI types A and D and reduce the pressure in the biliary tree [39]. Sphincterotomy may be performed without stenting; however, it is recommended in cases of biliary obstruction because of choledocholithiasis [39].

In cases when a minimally invasive approach does not solve patients' state, if there is biliary peritonitis and evidence of progressive sepsis, an operative exploration and washout are recommended [44].

In type A injuries, stents can be removed endoscopically usually after 2 weeks if there is no ongoing biliary leak on ERCP [39]. In types C and D injuries, repeated HIDA scans are recommended after 2–4 weeks after stent insertion and stents can be removed if there is no leak on a follow-up ERCP [39]. If the leak persists, stents can be replaced or sphincterotomy can be performed to facilitate the bile flow [39]. Patients with type D injuries require close follow-up due to stricture development or progression to type E injuries in case of larger defects of the biliary wall [39]. Also, endoscopic treatment is less effective in the type C injuries because the aberrant right hepatic duct is disconnected from the proximal part of the biliary tree [39].

Occlusive BDI of the right hepatic bile duct usually leads to segmental cholestasis, fibrosis, and right lobar atrophy. It can be asymptomatic but some patients can suffer from cholangitis or hepaticolithiasis. US and CT may show dilatated duct of the right part of the liver with focal atrophy of the liver tissue. ERCP and MRCP will show the site of the obstruction of the right hepatic duct. The treatment of this BDI is surgical. In case when fibrosis and atrophy are not advanced, a hepaticojejunostomy should be performed. Significant atrophy may require resection.

#### *8.2.2 Transections of common hepatic duct*

Type E injuries are localised at the common hepatic duct and are the most serious. Transections of the common hepatic duct are usually recognised at the time of

#### *Routine and Innovation in Surgical Therapy of Gallstones DOI: http://dx.doi.org/10.5772/intechopen.100570*

surgery, because of a biliary leak. If there is only a limited mural lesion of the common bile duct, placing a T-tube drain could be a solution. Primary repair attempts should be avoided, especially in case of normal diameter of the common hepatic duct and tissue loss because the probability for breakdown is high and it can lead to bile duct strictures during the healing process [44]. These attempts, especially if they are performed by an inexperienced surgeon, can make the future revisions more difficult [44]. Significant damage of the common hepatic duct is preferably solved by hepaticojejunostomy [44].

Clinical symptoms depend on the nature of an injury. Occlusive injuries lead to jaundice development and elevated liver function tests. Radiological examinations will show diffuse dilatation of intrahepatic bile ducts, and ERCP will verify complete obstruction of the common hepatic duct. In order to decompress the intrahepatic bile ducts, percutaneous transhepatic drainage (PTD) and percutaneous transhepatic cholangiography (PTC) should be performed. Both liver lobes have to be drained and it can require placing percutaneous drains to both intrahepatic parts of the biliary tree. In cases of strictures due to inappropriately placed clips or ligatures, ERCP with the dilatation and stent insertion may be helpful. Endoscopic treatment is not very effective in cases of complete occlusion and if the length of the stricture is longer than 1 cm. The treatment of choice is surgery and hepaticojejunostomy Roux-en Y [44, 47].

#### **8.3 Bleeding and vascular injury**

Bleeding from the gallbladder bed is not a rare complication, especially in cases of fibrotic changes in chronic cholecystitis. If laparoscopic attempts for bleeding control fail, it usually requires immediate conversion and ligation [48].

Arterial bleeding is usually caused by the cystic artery transection and can be controlled by clipping, but a surgeon must avoid injury to the right hepatic artery. Injuries of the right hepatic artery require a high level of technical expertise, and the efficiency of reconstruction is questionable. Many right hepatic artery injuries remain unrecognised because its interruption is usually well tolerated [44].

Bleeding from trocar sites should be avoided with direct visualisation after removal.

#### **8.4 Bowel injuries**

Bowel injuries are a rare complication. If the bowel injury is recognised intraoperatively, it must be unconditionally repaired. Unspotted bowel injuries may lead to sepsis development after the procedure and require broad-spectrum antibiotic treatment and laparotomy for reparation. Clinical symptoms involve abdominal pain, hypotension with tachycardia with the laboratory picture of leucocytosis or leucopenia, and elevated serum inflammatory markers. In cases when clinical symptoms are mild, a patient does not develop sepsis and an adequate drainage can be achieved, management can be continued as for controlled entercutaneous fistulas [39].

#### **9. Conclusion**

Nowadays, the laparoscopic cholecystectomy is the state-of-the-art surgical therapy for gallstones disease. The primary concept is the safety of the patient; therefore, the surgeon must be aware of the anatomy variations and has to be prepared to react to them. The first thing young residents have to learn is the technique of critical view of safety to reduce the risk of biliary duct injuries. Although we may do every effort to minimise the risks of complications, those will happen nonetheless. Therefore, every surgeon has to be aware of the basics in the management of cholecystectomy complications.
