Section 5 Bile Duct Injury

### **Chapter 6**

## Iatrogenic Biliary Injury Surgical Management

*Alex Zendel and Yaniv Fenig*

### **Abstract**

Bile duct injury (BDI) remains a critical complication following cholecystectomy. Prevention, early recognition, and appropriate management can significantly improve patient outcomes. In this chapter, we will discuss the current review of the surgical management of BDI, including prevention techniques during the cholecystectomy, intra-operative diagnosis of the injury, early evaluation and imaging, importance and challenges of the referrals to a hepatobiliary center, types and classification of biliary injuries, biliary drainage, and interventional procedures bridging to definitive repair, timing of surgical repair-early versus late, surgical repair techniques, evaluation and management of combined vasculo-biliary injury.

**Keywords:** prevention, intra-operative diagnosis, early referral, cholangiogram, percutaneous transhepatic biliary drainage, MRI/MRCP, early repair, delayed repair, hepato-jejunostomy, repair patency

### **1. Introduction**

Laparoscopic cholecystectomy (LC) continues to be one of the most frequent surgical procedures performed in the US and the world, while bile duct injury (BDI) is the most morbid complication of LC [1]. Multiple preventive techniques reduced this complication rate [2], but BDI is still described in all LC's at 0.1–0.5% range [3]. Due to the high numbers of cholecystectomies performed, it is an enormous healthcare problem often leading to long-term physical and psychological morbidity to patients, with mortality described up to 7% [4]. It also is associated with multiple interventions and hospitalizations that generate a significant cost and burden to the patient and healthcare system [5].

Prevention of BDI is of paramount importance. Over the years, various classifications of biliary injuries have been proposed, and different methods have been described to prevent iatrogenic biliary tract lesions. The optimal treatment is influenced by the timing of recognition of the injury, the extent of BDI, the patient's clinical condition, and the availability of experienced hepatobiliary surgeons. This chapter aims to discuss the current updated management of iatrogenic BDI.

### **2. Safe cholecystectomy and prevention of BDI**

### **2.1 Risk factors**

Anatomical:


Patient-related:


It has been demonstrated that the primary cause of BDI is the misinterpretation of biliary anatomy in 71–97% of all cases [6].

Over the years, various methods have been proposed and described to prevent iatrogenic biliary injury [7–9].

### **2.2 Surgical technique**

### *2.2.1 Anatomical landmarks*


*Iatrogenic Biliary Injury Surgical Management DOI: http://dx.doi.org/10.5772/intechopen.110424*

### **Figure 1.** *Line of safety is an important intra-operative landmark to prevent BDI.*

### *2.2.2 Dissection approach*


### *2.2.3 Final anatomical identification*

The "critical view of safety (CVS)" technique (**Figure 2**) was introduced by Strasberg in 1995, and it is considered the gold standard to perform a safe cholecystectomy [9, 15]. It implies the identification of biliary structures during dissection and includes 3 criteria:


**Figure 2.**

*Critical view of safety is a "gold standard" anatomical confirmation for safe cholecystectomy.*

### **2.3 Intra-operative tools**

### *2.3.1 Intra-operative cholangiography (IOC)*

It has been proposed for the better declaration of biliary anatomy, detection of silent CBD stones, and reduction of incidence of BDIs [16]. The opinions about the "routine" or "selective" use of IOC still represent a matter of debate, but the selective approach is considered to have comparable chances of preventing and detecting BDI [17, 18]. However, it is highly advised to use IOC in any case of difficult LC or when there is a concern about biliary anatomy identification [18, 19].

### *2.3.2 Intra-operative ultrasound (IOUS)*

It was shown to provide a highly sensitive mapping of the extra-hepatic biliary anatomy [20], but the difficult learning curve and the lack of randomized controlled trials have reduced its use in clinical practice.

### *2.3.3 Fluorescent cholangiography*

It represents a novel intra-operative imaging technique that allows real-time enhanced visualization of the extrahepatic biliary tree by fluorescence, after the intravenous injection of the dye indocyanine green (ICG) [21]. It is a safe and useful method that became a common practice in difficult cholecystectomy [22, 23]. However, under the conditions of severe inflammation, this imaging can be less clear, and then, a strong consideration to bail out is suggested (**Figure 3**).

### **2.4 When to bail out**

"Inflection point"—the moment the decision is made to complete formal laparoscopic cholecystectomy [24].

The general rule is that it should happen sooner than later before the injury happens. The consequences of bailing out are usually less morbid than those of biliary injury.

The following factors may influence personal surgeon's decision toward the inflection point [24, 25]:

#### **Figure 3.**

*A real-time enhanced visualization of the extrahepatic biliary tree by fluorescence, after the intravenous injection of the dye indocyanine green (ICG).*

*Iatrogenic Biliary Injury Surgical Management DOI: http://dx.doi.org/10.5772/intechopen.110424*


### **2.5 How to bail out**

### *2.5.1 Laparoscopic subtotal or partial cholecystectomy*

### *2.5.1.1 Fenestration type - preferred method*

Fenestration of the gallbladder anterior wall, leaving the posterior wall attached to the liver, ablating the mucosa, and securing the cystic duct at its origin from the mucosal side within the gallbladder [26].

Pros: usually easy recognition of the cystic duct origin, reduced blood loss with no need to dissect the gallbladder bed from the liver, usually no need for a conversion to open procedure.

### *2.5.1.2 Reconstitution type - optional method: resection of most of the gallbladder and leaving the small stump*

Pros: can prevent BDI in complex cases.

Cons: risk for neo-gallbladder appearance, recurrent stones, possible need for cholecystectomy completion, which is likely more complex and high-risk compared to the index one.

### *2.5.2 Conversion to the open procedure*

Pros: usually allows cholecystectomy completion, improved recognition of the anatomy including vascular structures [24–26].

Cons: morbidity related to the open incision, lack of experience of modern surgeons in open cholecystectomy.

A general recommendation is that in all cases of complicated cholecystectomies, the surgeon must not hesitate when considering bailing out from the completion of formal LC, because the consequences may be dramatic.

### **3. Diagnosis**

### **3.1 Clinical presentation**

Depending on the timing of diagnosis and type of injury, it can be divided as followings by pathophysiology:

### *3.1.1 Asymptomatic/at the time of LC*

### *3.1.1.1 Biliary leak*


### *3.1.1.2 Biliary obstruction and stricture*


### **3.2 Non-invasive imaging**

Radiologic investigations should be obtained for the correct identification of the damage, its extension, and gravity and to plan therapeutic strategies.

### *3.2.1 Ultrasonography (US)*

A primary and easily available diagnostic tool that allows finding fluid collections, dilation of the bile ducts, and possibly associated vascular lesions, using Doppler evaluation [27].

### *3.2.2 Computed tomography (CT)*

Superior to the US in detecting fluid collections, and guiding their percutaneous drainage, but similar to the US is not reliable in distinguishing bile leaks from other postoperative fluid collections, such as blood, pus, or serous fluid, because of their similar densities [28–30]. It can also show biliary obstruction with upstream dilatation, or long-term sequelae of a long-standing bile stricture, such as lobar hepatic atrophy or signs of secondary biliary cirrhosis. The CT scan is specifically useful to identify any associated vascular lesions.

### *3.2.3 Hepatobiliary scintigraphy (HS)*

It seems to be more sensitive and specific than US or CT in detecting bile leaks and can provide functional information demonstrating the presence of an active leak [31]. However, its spatial resolution is poor, and the identification of the leak site can be challenging. In addition, it is limited in providing the exact anatomy of the whole biliary tree and in patients with hepatic dysfunction, and large leaks have poor sensitivity and can show no extrahepatic bile duct [32]. Because of those limitations, it is

*Iatrogenic Biliary Injury Surgical Management DOI: http://dx.doi.org/10.5772/intechopen.110424*

rarely used as a standalone test, and its use is replaced mostly by magnetic resonance imaging.

### *3.2.4 Magnetic resonance imaging with cholangiopancreatography (MRI/MRCP)*

A non-invasive "gold standard" for the complete morphological evaluation of the biliary tree as it offers detailed information about the integrity of the biliary tract [28, 33]. The use of a gadolinium contrast agent during MRI/MRCP allows the detection of active bile leakage by direct visualization of contrast material extravasation into fluid collections in addition to demonstrating the anatomical site of the leakage and the type of BDI, and thus, it is superior to CT and US in specifying the collection as biloma [34, 35].

### **3.3 Invasive cholangiography**

### *3.3.1 Types used*


### *3.3.2 General advantages*


### *3.3.3 General disadvantages*


### *3.3.4 Specific considerations*

### *3.3.4.1 ERCP*


### *3.3.4.2 PTC*


### **4. Classification**

The location of BDI on the biliary tree is of primary importance in deciding management and predicting outcomes. We suggest using classification introduced by Strasberg in 1995 [7], as its comprehensive anatomical and functional injury description allows repair guidance and stratifies the risk for long-term complications, such as biliary stricture [41].

**Figure 4** Strasberg classification.

Type A: bile leakage from either the minor bile ducts from gallbladder bed or the cystic duct.

Type B and C: occlusion (type B) or transection (type C) of aberrant right hepatic ducts.

Type D: lateral damage to the common bile duct resulting in a biliary leak.

Type E: involve the main ducts and are classified according to the level of injury in the biliary tree. Each type corresponds to the same type of Bismuth classification:

E1 - >2 cm from the confluence.

E2 - <2 cm from the confluence.


**Figure 4.** *Strasberg's classification of BDI.*

### **5. Timing of diagnosis and repair**

Early and delayed repair are both acceptable approaches to a definite repair of BDI. The big question exists regarding an exact definition of "early" vs. "delayed". The data is mixed, and the time from the initial surgery is defined as between 0 and 21 days for early [5, 8, 12, 13] and after 4–6 weeks as "delayed" [8, 12].

Advantages of early approach:


Advantages of delayed approach:


### **5.1 Choice of the early versus delayed repair**

### *5.1.1 Timing*

Based on most recent evidence, we recommend considering early repair within 48– 72 hours from the injury [40, 42, 43]. Some data suggests the earlier the repair, the better the results [4, 44, 45] whereas other support comparable good outcomes within 72 hours timeframe [46].

When missed the opportunity window of 48–72 hours for an early repair, it is advised to delay it for at least 4–6 weeks [37, 43, 47]. This will allow to decrease the degree of local inflammation, control infection, and optimize the conditions for a complex reconstruction.

### *5.1.2 Expertise*

The repair of a bile duct injury is a complicated procedure, and there is clear evidence that the best results are obtained at a center with experienced hepatobiliary surgeons [43, 48–50]. It is a single most important factor in the success of the repair. At attempt to perform an immediate repair by an unexperienced surgeon is associated with worse outcomes and can compromise the future repair by a specialist, in case of repair complications [43, 50].

### *5.1.3 Type of injury*

In the presence or suspicion for a vascular injury, one should consider delaying a repair to complete a comprehensive work-up and to allow the injury present and establish its clinical significance [43, 51].

### **5.2 Early repair**

### *5.2.1 Immediate recognition of the injury at the time of LC*

After the prevention of the injury, the surgeon's awareness to suspect and evaluate for a BDI is the second most important factor in determining the patient prognosis.

### *5.2.1.1 Immediate intra-operative repair*

If the required surgical expertise is present, we suggest following steps:


### *5.2.1.2 Early transfer to a tertiary referral center*

If the competent surgeon capable of performing a biliary reconstruction is not present, we advise to follow the next steps:


### *5.2.2 Early recognition after completion of cholecystectomy*

At the same admission it presents as described earlier symptoms and signs of biliary leak, obstruction, or both. A general recommendation is that any alteration in the normal postoperative course after LC must suggest a possible damage to the biliary tract. Sometimes, the evolution of biliary symptoms is subtle, so high degree of clinical suspicion and careful clinical evaluation of patients are essential. It will allow the thorough and prompt inpatient evaluation and/or referral to a tertiary specialty center.

The diagnosis after the discharge is often made based on clinical symptoms, which means more advanced and complicated problem, or based on abnormal lab tests, in case of milder injury.

To allow the chance of early repair, one should apply similar principles as described in case of intra-operative injury recognition:

*5.2.2.1 Perform prompt biliary imaging to evaluate the type of the injury and provide the drainage of biliary system*

US:


MRCP:


### CT:


### ERCP:


PTC:


Drain any biloma or abscess percutaneously if operative drain is not present or is not providing adequate drainage—to prevent and treat bile peritonitis and sepsis, as well as to control the ongoing leak [52].

### *5.2.2.2 Make the decision about the possibility of early repair, based on factors discussed earlier*

• Presence of competent hepatobiliary surgeon


### **5.3 Delayed repair**

### *5.3.1 The conditions leading to choosing the delayed repair approach*


### **6. Management and repair of minor BDI—types A-D**

### **6.1 Type A injury**

### *6.1.1 Non-operative management*


### *6.1.2 Operative repair*


### **6.2 Type B injury**

	- Is appropriate when a segmental or accessory ligated duct is small (usually up to 3 mm) and cholangiography demonstrates adequate drainage of the segment with an injured bile duct.

• Temporary percutaneous drainage (PTC) can be placed to control cholangitis in the obstructed segment.

### *6.2.2 Operative repair*


### **6.3 Type C injury**

### *6.3.1 Non-operative management*


### *6.3.2 Operative repair*


Injuries grade D and above usually will require operative intervention.

### **6.4 Type D injury**

### *6.4.1 Non-operative management*


### *6.4.2 Operative repair*


### **7. Management and repair of major BDI—types E injury (transection, clipping, or stricture of major bile ducts)**

### **7.1 Non-operative management**

### *7.1.1 ERCP*


### *7.1.2 PTC*


### **7.2 Primary anastomosis of the bile duct-choledocholedochostomy**

### *7.2.1 Why to attempt-advantages on bilioenteric reconstruction*


### *7.2.2 Can be performed in selected cases-conditions to perform*


### *7.2.3 An exceptional clinical judgment is required to decide about the primary bile duct*

reconstruction as this approach is associated with increased failure rate compared to bilioenteric reconstruction, especially when it is performed beyond the conditions mentioned above [50, 57, 72].

### *7.2.4 Choledocholedochostomy-operative technique*


### **7.3 Bilioenteric reconstruction—Roux-en-Y hepatojejunostomy**

It represents a gold standard surgical repair of major bile duct injuries and is being performed as a definite repair in most cases of BDI [7, 43, 49, 73]

### *7.3.1 Advantages*


### *7.3.2 Roux-en-Y Hepato-jejunostomy-surgical technique*


### *7.3.3.1 Type E1–2*

Single duct bilioenteric anastomosis.

*7.3.3.2 Type E3*

• If the bile duct bifurcation maintained as a single orifice allowing technically feasible reconstruction—can perform single bilioenteric anastomosis

**Figure 5.** *Roux-en-Y Hepato-jejunostomy - surgical technique.*

• If not, two separate right and left anastomoses should be performed.

### *7.3.3.3 Type E4*


### *7.3.3.4 Type E5*


### *7.3.3.5 Technical solutions in complicated cases*

• In order to achieve sufficient bile duct caliber side-to-side technique may be preferred, including opening the left hepatic duct but keeping the posterior wall of the bifurcation to preserve the blood supply, according to the Hepp-Couinaud technique [75, 76].

### **8. Vasculobiliary injury (VBI)**

This is defined as a combined injury to a bile duct and to an accompanying major blood vessels in the porta hepatis.

Types of VBI [75]:


### **8.1 Classic VBI**

### *8.1.1 Injury to the RHA below the biliary confluence (usually type E1/E2)*

Does not usually cause a clinically significant ischemic injury to the liver parenchyma, due to a shunt that occurs immediately from the left hepatic artery (LHA) traveling via the transverse hilar marginal artery (THMA) to the right liver [76].

*8.1.2 Injury to the RHA above the biliary confluence of the ducts*

• Will disrupt the collateral biliary blood supply including THMA.


### **8.2 Impact of VBI on definite repair approach**

### *8.2.1 Diagnosis*


### *8.2.2 Timing of repair*


### *8.2.3 Surgical approach to repair*


### *8.2.4 Arterial reconstruction*

• Usually, it is not possible to reconstruct the RHA and indeed it is not necessary, because of little clinical significance of liver disfunction.

### *8.2.5 Outcomes*

• With the right surgical classic VBI can be managed with the outcomes comparable to BDI without vascular injury [40].

### **8.3 Extreme VBI**


### **9. Conclusions**


### **Acknowledgements**

Chirag S Desai, MD, University of North Carolina at Chapel Hill, Division of Abdominal Transplantation for the mentorship, guidance, and friendship.

### **Thanks**

Thanks to my family, colleagues, and mentors, this book chapter publishing would not be possible without their support.

### **Author details**

Alex Zendel<sup>1</sup> \* and Yaniv Fenig<sup>2</sup>

1 University of North Carolina at Chapel Hill, NC, US

2 SUNY Downstate Health Sciences University, Brooklyn, NY, US

\*Address all correspondence to: drazendel@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Iatrogenic Biliary Injury Surgical Management DOI: http://dx.doi.org/10.5772/intechopen.110424*

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### *Edited by Qiang Yan and Zhiping Pan*

Biliary tract disease is a common digestive system disease worldwide that can present with mild clinical signs or be life-threatening. This book discusses the pathogenesis, diagnosis, and management of four common bile diseases: common bile duct stones (CBDS), choledochal cyst (CC), gallbladder cancer (GBCa), and bile duct injury (BDI).

Published in London, UK © 2023 IntechOpen © defun / iStock

Biliary Tract - Review and Recent Progress

Biliary Tract

Review and Recent Progress

*Edited by Qiang Yan and Zhiping Pan*