Biliary system Gastro 54 CBD Problems

• (A) Bile leak from cystic duct stump or minor biliary radical in gallbladder fossa.
• (B) Occluded right posterior sectoral duct.
• (C) Bile leak from divided right posterior sectoral duct.
• (D) Bile leak from main bile duct without major tissue loss.

• Bismuth Classification
• (E1) Transected main bile duct with a stricture more than 2 cm from the hilus.
• (E2) Transected main bile duct with a stricture less than 2 cm from the hilus.
• (E3) Stricture of the hilus with right and left ducts in communication.
• (E4) Stricture of the hilus with separation of right and left ducts.
• (E5) Stricture of the main bile duct and the right posterior sectoral duct.
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Class I - CBD is mistaken for the cystic duct, but the error is recognized before CBD is divided.

Class II - damage to CHD from clips or cautery used too close to the duct. This often occurs in cases where visibility is limited due to inflammation or bleeding.

Class III - the most common type, CBD is mistaken for the cystic duct. The common duct is transected and a variable portion including the junction of the cystic and common duct is excised or removed.

Class IV - damage to the right hepatic duct (RHD), either because this structure is mistaken for the cystic duct, or because it is injured during dissection

• 1. Use the Critical View of Safety (CVS) method of identification of the cystic duct and cystic artery during laparoscopic cholecystectomy
• 2. Consider an Intra-operative Time-Out during laparoscopic cholecystectomy prior to clipping, cutting or transecting any ductal structures.
• 3. Understand the potential for aberrant anatomy in all cases.
• 4. Make liberal use of cholangiography or other methods to image the biliary tree intraoperatively
• 5. Recognize when the dissection is approaching a zone of significant risk and halt the dissection before entering the zone. Finish the operation by a safe method other than cholecystectomy if conditions around the gallbladder are too dangerous.
• 6. Get help from another surgeon when the dissection or conditions are difficult.

• Technique
• Use high-quality imaging equipment
• Before starting the dissection, use the triangle of Calot for orientation; find the cystic duct, starting at the triangle
• Pull the gall bladder infundibulum laterally to open the triangle of Calot
• Clear the medial wall of the gall bladder infundibulum
• Make sure the cystic duct can be traced uninterrupted into the base of the gall bladder.
• Open any subtle tissue plane between the gall bladder and presumed cystic duct; the real cystic duct may be hidden in there

• Factors that suggest one may be dissecting the common duct instead of the cystic duct:
• The duct is not fully encompassed by a standard 9-mm clip
• Any duct that can be traced without interruption to course behind the duodenum is probably the CBD
• The presence of another unexpected ductal structure
• A large artery behind the duct – the right hepatic artery runs posterior to the CBD
• Extra lymphatic and vascular structures found in the dissection
• The proximal hepatic ducts fail to opacify on operative cholangiograms

• Obtain operative cholangiograms liberally Whenever the anatomy is confusing
• When inflammation and adhesions result in a difficult dissection
• Whenever a biliary anomaly is suspected; assume that what appears to be anomalous anatomy is really normal and confusing until proved otherwise by cholangiograms

Convert to an open procedure when inflammation or bleeding obscures the anatomy

• Accumulation of bile in the right subphrenic or subhepatic space after a Cholecystectomy or bile duct injury.
• It is characterized by upper abdominal or chest pain associated with tachycardia and persistently low blood pressure due to compression on IVC, that can be mistaken for coronary thrombosis.

When bile duct injury is suspected intraoperatively, conversion to an open operation and use of cholangiography help delineate management

• Small duct
• Ducts < 3 mm that by cholangiography drain only a single segment or sub-segment of liver, simple ligation should suffice for management.
• Ducts > 3 mm - usually drain more than a single segment of liver and thus, if transected, should be re-implanted into the biliary tree.

Larger duct - 

I) Not caused by electrocautery and involves less than 50% of the circumference of the wall - T tube placed through the injury

• II) Cautery injury  or an injury involving more than 50% of the duct circumference - resection of the injured segment with anastomosis to reestablish biliary enteric continuity.
• A) Defect < 1 cm and not near the hepatic duct bifurcation - mobilization with end-to-end anastomosis of the bile accompanied with trans anastomotic T tube placement. The tube should be inserted through a separate choledochotomy,and not exit the bile duct though the anastomosis.
• B) Injuries  adjacent to the bifurcation or involve > 1-cm defect between the ends of the bile duct - require reanastomosis to the gastrointestinal tract. 
• i) Low injuries to the bile duct - tension free Choledochoduodenostomy
• ii) Higher in the biliary tree, close to the hilum -  Roux-en-Y HJ

• 1. Control of infection, limiting inflammation
• • Parenteral antibiotics
• • Percutaneous drainage of periportal fluid collections

• 2. Clear and thorough delineation of entire biliary anatomy
• • MRCP or PTC
• • ERCP (especially if cystic duct stump leak is suspected)

• 3. Reestablishment of biliary-enteric continuity
• • Tension-free, mucosa-to-mucosa anastomosis
• • Roux-en-Y hepaticojejunostomy
• • Long-term transanastomotic stents if bifurcation or higher is involved

• Blumgart Kelley - end to side HJ 
• Segment III bypass 
• Hepp Couinard technique