CLASSIFICATION OF BILE DUCT INJURY.pptx

bile duct injuries classifications.

1. CLASSIFICATION OF BILE DUCT INJURY Dr Karrar Adil

2. Introduction : Laparoscopic cholecystectomy is now the gold standard for symptomatic cholelithiasis , but it is associated with a higher incidence of bile duct injury than open cholecystectomy. Numerous reports have demonstrated that the incidence of bile duct injuries has risen from 0.1%-0.2% to 0.4 %-0.7% from the era of open cholecystectomy to the era of laparoscopic cholecystectomy.

3. Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location . Over the years, many classifications of IBDIs have been occurred before and after the laparoscopic era to ensure adequate treatment planning.

4. Bismuth classification : Is the first classification of bile duct injury, authored by H. Bismuth in 1982 . is a simple classification based on the location of the injury in the biliary tract and is very helpful in prognosis after repair. was introduced before laparoscopy. It is difficult to apply in laparoscopic cholecystectomy as most of the technical factors and lesion mechanisms are completely different to open surgery. 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.

5. Bismuth type I : involves the common bile duct and low common hepatic duct (CHD) >2 cm from the hepatic duct confluence. Bismuth Type II : involves the proximal CHD <2 cm from the confluence. Bismuth Type III : is hilar injury located at the confluence with the ceiling of it still being intact. Bismuth Type IV : is destruction of the confluence when the right and left hepatic ducts become separated. Bismuth Type V : involves the aberrant right sectorial hepatic duct alone or with concomitant injury of CHD .

6. Strasberg classification 1995 : The Strasberg classification is a modification of the Bismuth classification, is very simple which can be easily applied to bile duct injuries . A llows 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.

7. Class A : Bile leak from cystic duct stump or minor ducts in gallbladder fossa . Class B : Occluded right posterior sectoral duct . Class C : Transection without ligation of the right posterior sectoral duct. Class D : Lateral injuries to major bile ducts. Class E : Subdivided as per Bismuth's classification into E1 to E5 : E1 - Stricture/injury at more than 2 cm distal to bifurcation. E2 - Stricture/injury less than 2 cm distal to bifurcation. E3 - Stricture/injury at bifurcation. E4 - Stricture/injury involving right and left hepatic ducts. E5 - Complete obstruction of entire bile duct.

8. Stewart-Way classification : P ublished in 2007. This classification system is based on the mechanism and anatomy of bile duct injuries and also includes concomitant vascular injuries. Bile duct injuries fall into four classes according to this classification :

9. Class I injury : O ccurs when CBD is mistaken for the cystic duct, but the error is recognized before CBD is divided. Associated RHA injury (5%).

10. Class II injury : 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 . Associated RHA injury (20%)

11. 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 . Associated RHA injury (35%)

12. Class IV injury : 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 . Damage to Right hepatic artery (60%) which is mistaken for cystic artery.

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