cbd injuries

Cbd injuries

The Strasberg classification is a modification of the Bismuth classification, but allows differentiation between small (bile leakage from the cystic duct or aberrant right sectoral branch) and serious injuries performed during laparoscopic cholecystectomy as type A to D. Type E of the Strasberg classification is an analogue of the Bismuth classification. 3 The Strasberg classification, summarized in Fig. 1 , is very simple which can be easily applied to bile duct injuries. The major disadvantage of the Strasberg classification is that it does not describe additional vascular involvement at all. For this reason, the Strasberg classification could not demonstrate a significant association between the discrimination of specific injury patterns and the resection of liver tissues.

Department of Surgery, Chungnam National University Hospital, Daejeon, Korea.

McMahon et al. proposed another classification of bile duct injuries after laparoscopic cholecystectomy. They classified the injury by the width of bile duct injury. Based on the McMahon classification, lacerations under 25% of the common bile duct (CBD) diameter or cystic-CBD junction was classified as minor injury, whereas transection or laceration over 25% of CBD diameter and postoperative bile duct stricture were classified as major injury. 2

Strasberg classification

The first classification of bile duct injury is authored by H. Bismuth in 1982. Up to now, a number of classifications have been proposed by different authors. The Bismuth classification is a simple classification based on the location of the injury in the biliary tract. This classification is very helpful in prognosis after repair. This classification included five types of bile duct injuries according to the distance from the hilar structure especially bile duct bifurcation, the level of injury, the involvement of bile duct bifurcation, and individual right sectoral duct. 14 Type I involves the common bile duct and low common hepatic duct (CHD) >2 cm from the hepatic duct confluence. Type II involves the proximal CHD <2 cm from the confluence. Type IIIis hilar injury with no residual CHD confluence intact. Type IV is destruction of the confluence when the right and left hepatic ducts become separate. Type Vinvolves the aberrant right sectoral hepatic duct alone or with concomitant injury of CHD. However, the Bismuth classification does not include the wide spectrum of possible biliary injuries.

Strasberg classification. 3 , 22 (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. (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.

Since its introduction, laparoscopic cholecystectomy has become the gold standard treatment for gallstone disease. 1 However, the incidence rate of bile duct injury (BDI) has risen from 0.06% to 0.3%. Open cholecystectomy has risen from 0.5% to 1.4% when gallbladder removal is performed laparoscopically. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 In initial studies on the removal of laparoscopic gallbladder, complications such as bleeding, wound infection, respiratory insufficiency, trocar injury to the intra-abdominal viscera, major vascular injury, and bile leaking accounted for reported morbidity rate ranging from 1.0% to 8.0%. 2 , 3 , 4 , 5 , 6 , 7 , 8 Despite the completion of the learning curve and the recognition of preventive maneuvers to avoid ductal injury during laparoscopic cholecystectomy, the incidence rate of BDI remains unchanged. 13 In addition, injuries of the bile duct system after laparoscopic cholecystectomy are more complex than that after an open approach, causing significant morbidity and even death. Associated vascular lesions, particularly injuries to the right hepatic artery or longitudinal strictures of the common bile duct due to failed repair attempts, are not uncommon. Various classifications of bile duct injuries after laparoscopic cholecystectomy were reviewed in this article.


Laparoscopic cholecystectomy is now a gold standard treatment modality for gallstone diseases. However, the incidence rate of bile duct injury has not been changed for many years. From initial classification published by Bismuth, there have been many classifications of common bile duct injury. The initial classification, levels and types of bile duct injury, and currently combined vascular injuries are reviewed here.

Bile duct injuries fall into four classes based on the Stewart-Way classification. 15 Class I injury occurs when CBD is mistaken for the cystic duct, but the error is recognized before CBD is divided. Class II injuries involve 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 injury, the most common type, occurs when 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 injuries involve damage to the right hepatic duct (RHD), either because this structure is mistaken for the cystic duct, or because it is injured during dissection ( Fig. 2 ). Both complex bileduct and vascular injuries were included in the Stewart-Way classification.

Cbd injuries

Hepatectomy is rarely required for IBDI; however, in case of failure of reconstructive approaches, it remains a necessary option. The ultimate rescue therapy available would be LT, but the indications are exceptional and reserved for patients in whom liver function is so deteriorated that repair or partial hepatectomy is impossible. These include:

In the future, ultrasound and intraoperative fluorescence cholangiography may help to reduce IBDI. In this respect, near-infrared fluorescence cholangiography (NIRFC) was developed [32,33,34] and a multicenter randomized controlled trial is currently recruiting to compare NIRFC-assisted laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy (FALCON trial) [35]. When employing this method, intravenous injection of a dye (indocyanine green) and use of specific equipment, i.e. an NIR light-emitting xenon-based light source and a camera that is capable of detecting NIR fluorescence emitted by indocyanine green-dyed bile, is required [36]. Neither the dye (at normal doses) nor the equipment is dangerous (no irradiation) for the patient or surgeon. Compared with IOC, NIRFC has been shown to be quicker to perform and to cost less [37]; however, an increased safety has yet to be proven. Theoretically, it should be possible to perform NIRFC in all cases (vs. a 93% rate for IOC) because of the impossibility to cannulate the cystic duct (which represents a dangerous risk factor!) [38,39].

Stewart-Way classification of laparoscopic bile duct injuries (modified from [41]).

a, b Critical view of safety (CVS).

Cystic Duct Leaks

– uncontrolled sepsis of the entire biliary tree, in the presence of severe intrahepatic bile duct strictures or metallic stents [67,68,69];

Cystic duct leaks are well manageable; the treatment of choice is endoscopic retrograde cholangiopancreatography and sphincterotomy [13] or endoscopic stenting and drainage of intra-abdominal bile collections. Nearly all cystic duct leaks will close with this management scheme. It is crucial to drain bile collections; the stent only acts to decrease the pressure in the biliary tree and does neither cover the leak nor prevent bile drainage.

The older classifications are based on peripheral leakages, central leakages, and biliary strictures. Siewert et al. [40] described type 1 lesions, which are peripheral leakages and include immediate biliary fistulas. In contrast, central leakages consist of tangential lesions without structural loss of the bile duct and correspond with type 3 lesions [40]. Type 2 lesions occur when late strictures are diagnosed without obvious intraoperative trauma [40]. Table ​ Table1 1 and ​ and2 2 present the Corlette-Bismuth classification and the Strasberg classification, respectively.

Prevention of Bile Duct Injuries

Cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery, and the laparoscopic approach is now the gold standard for symptomatic cholecystolithiasis as well as for chronic and acute cholecystitis [1]. Besides the advantages of a distinctly faster recovery and better cosmetic results, the laparoscopic approach bears a higher risk for iatrogenic bile duct injury (IBDI) and injury of the (right) hepatic artery. IBDI is a complication associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation [2]. Despite increasing experience and progress in laparoscopic skills of surgeons, the incidence of IBDI is still elevated compared to open cholecystectomy [2]. The rate of clinically relevant bile leaks after conventional open cholecystectomy ranges between 0.1 and 0.5% [3,4,5,6]. In contrast, biliary leakages have increased in the era of laparoscopic cholecystectomy (LC) by up to 3% [7,8,9,10]. A variety of injuries can occur. Besides minor bile leakage of aberrant ducts, cystic stump or the main bile duct, complete occlusion of the main duct or a branch (often an aberrant right duct) can happen. In addition, bile duct strictures and biliary leakages are severe long-term complications after LC. These injuries are associated with high morbidity, mortality, and prolonged hospitalization [11]. Currently, endoscopic procedures are most frequently used in the management of postoperative IBDI. There are several endoscopic techniques available, e.g. biliary stent placement, biliary sphincterotomy, and nasobiliary drainage [12,13,14]. In this respect, endoscopic therapy can reduce the transpapillary pressure gradient and improve the transpapillary flow, which decreases the extravasation out of the biliary tract. This reduction of bile leakage allows healing of duct lesion injuries without direct surgical repair. Nonetheless, if major IBDI occurs, i.e. complete dissection of the common bile duct (CBD), surgical management is required to resolve this issue [15]. In an effort to reduce further complications and injuries in the hepatoduodenal ligament, surgical procedures should be performed in collaboration with skilled and experienced hepatobiliary surgeons, interventional radiologists, and gastroenterologists at a tertiary referral center [16,17].

Several studies reported that the timing of biliary reconstruction influences the outcome; these series reported worse outcomes for biliary reconstructions performed within 6 weeks of injury [52,54,65]. Stewart and Way [48] examined this question, using multivariate analysis, and noted that the timing of repair was not an independent predictor of successful biliary repair. Instead, success correlated with eradication of intra-abdominal infection, complete preoperative cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. This timing issue most likely relates to the time required to eradicate intra-abdominal inflammation and to achieve nutritional repletion. In this series, good results were achieved with early biliary reconstruction in those patients with good nutrition, good functional status, and early control of intra-abdominal inflammation [48].

Cbd injuries

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