Management of Common bile duct injuries

kathmandu medical college, department of surgery

1. Management of CBD injuries Dr. Uttam Laudari First Year Resident 01/31/2015

2. Recognized at time of cholecystectomy Experienced surgeon Its not immediately desperate always worth waiting for another opinion and technical assistance Each failed repair is associated with some loss of bile duct length

3. No assistance Place drain to control any biliary leak and REFER

4. ABANDON LAPARASCOPIC APPROACH RIGHT SUBCOSTAL/EXTENDED SUBCOSTAL AND CHEVRON INCISION Operative cholangiography to dilineate anatomy and type of injury

5. Aim Maintenance of ductal length below the hilus with out scarifying tissue Avoidance of uncontrolled postoperative bile leak

6. Small ducts injury difficult to repair Insert external drainage by placing tube proximally into the bile duct and REFER then to repair which is likely to fail Aim at maintaining length and preventing fistulation

7. Complete transection End to end repair over T- tube Transected ends should be apposed without tension Mobilization of duodenum and head of pancreas Single layer of interrupted absorbale suture with T tube brought out of bile ducts away from anastomosis Silk suture- avoid- promotes inflammatory reaction and nidus for stone formation Drawback- 50-60% stricture Roux eny HJ better for long term results and is recommended

8. Lateral duct wall injuries Small/ simple laceration repair with interrupted 4-0, 5-0 absorbable suture T- tube ?? uncecessary Decompressed bile duct may exacerbate injury while placement

9. Long lateral wall injuries Impossibe for transverse repair without compromising lumen Direct repair over T- tube – future stenosis Use of – veins patch, cystic duct stump, pedicled flap of jejunum, Roux loop of jejunum as serosal patch

10. T- tube placed across the defect and its long limb led out through roux loop and exteriorized through abdominal wall cavity

11. Advantage- Bile duct maintained Jejunal serosa used to cover defect secured in place with fine interrupted sutures to bile duct without attempting direct approach to ragged edge of damaged duct T- tube causes bile decompression across jejunum so that when it is removed any leaking bile will drain into the bowel lumen rather abdominal cavity

12. Injury recognized in immediate postop period Mode of presentation Bile drainage through wound Biliary peritonitis Progressive jaundice Or depends on the type of injury

13. External biliary fistula Avoid early reoperation Investigate Nutrition Free from sepsis Fistulography - bilioenteric communication prolong drainage spontaneous closure if no distal obstruction

14. Severe lacerations or complete transections Biliary tree decompressed  difficulty operation Adequate repair requires Exposed healthy bile duct mucosa within a sufficiently dilated proximal system to allow precise anastomosis Decompressed bile ducts and inflamed Technically demanding, delayed approach most appropriate– for spontaneous closure and time for proximal systems dilatation

15. high output biliary fistula for prolong time  creation of temporary internal fistulojejunostomy and definitve mgmt later Or placement of endoscopic sphincterotomy to facilitate bile drainage and decrease the fistula output. such procedures require 2-3 weeks time to intervene and by that time most fistula close or decrease substantially

16. Biliary peritonitis Bile drainage and controlling ongoing leak is primary objective Percutaneous abscess drains, or percutaneous bilirary catheters Definitive repair difficult as bile ducts are collapsed, deeply bile stained and best delayed untill biliary leak completely controlled and fully resuscitated

17. Injury presenting at interval after initial operation Present as biliary strictures Principles Exposing healthy proximal bile ducts draining all areas of liver Preparation of suitable segment of distal mucosa for anastomosis Creation of mucosa to mucosa sutured anastomosis of bile ducts to distal conduits

18. Staged approach to stricture repair in the presence of intrabdominal infection, portal hypertension, and poor general condition External bile drainage Sepsis control Treating existing condition

19. Technical approach to biliary aproach End to end duct repair Excision of stricture with end to end anastomosis Establishing normal anatomical continuity and drainage via intact sphincter of oddi 50-60 % long term failure Limited role

20. Biliary Enteric repair procedures Procedure of choice in most cases Choledochoduodenostomy - Stricture of retropancreatic or immediate portion of CBD Side to side/end to side anastomosis Appropriate only in setting of dilated CBD Recurrent stricture high chance if created in decompressed duct

21. Stricture of common hepatic duct Difficult to manage, specially those involving biliary confluence Almost always require Roux en Y HJ

22. Striture Type I and II ( below the confluence) Direct anastomosis to hepatic duct stump Type III and Type IV Difficult to achieve good results Choice of surgical approach should be tailored tailored to height and extent of lesion

23. Type III and IV stricture Biliary enteric anastomosis to left hepatic duct provides complete drainage of both left and right ductal system

24. Type III/IV Division of falciform ligament Freeing liver from adhesion Starting dissection from Right subhepatic area Mobilizing hepatic flexure of colon below and working upward and medially Mobilizing duodenum- may be adherent to undersurface of liver and hilar structures particularly in are of stricture

25. Identifying duct below the strictures are unnecessary, as distal duct generally cannot be used for anastomosis Also extensive dissection to free it risks injury to heptic artery and portal vein Identification of bile duct proximal to stricure

26. In generally much easier and safer to expose the left hepatic duct by lowering the hilar plate at base of segment IV ( quadrate lobe) As this area has not been disturbed by previous surgeries and is likely to relatively free from adhesions This maneuver delivers left hepatic duct and biliary confluence from under surface of liver and makes identification of stricutred area much easier

27. Adhesions posterior to damaged duct may be dense, extensive dissection in this situation risks injury to underlying portal vein

28. Ligamentum teres approach Rarely used procedure when there is dense adhesions, bleeding or large overhanging quadrate lobe Sometime extra hepatic length of left hepatic duct may be relatively short and oblique making other approach difficult

29. Mucosal graft procedures of Smith Introduced for treating high strictures Where hilar dissection is impossible and proximal ducts cannot be delivered for mucosa to mucosa anastomosis Utilizes trashepatic tube to draw jejunal mucosa high up into the hepatic ducts and allowing apposition Hepatic tubes left in place for 2-6 month

30. Drawbacks Dome of jejunal mucosa drains into the hepatic ducts which blocks secondary intrahepatic ducts and isolating segments of liver tissue Mucosa slips postoperatively and jejunal loop detaches Recurrent stricture at previous mucosal grafts

31. Liver split and liver resection To expose the bile duct for repair  Hepatotomy By opening umbilical fissure for access to segment III or extending subhepatic approach to expose origin of RHD Upward mobilization of quadrate lobe and opening the umbilical fissure facilitates access for type IV strictures when access to RHD is difficult

32. Longmire approach Intrahepatic hepaticojejunostomy Resection of left lateral segment (II and III) and anastomosis to ducts exposed on the cut surface of liver. Difficult and dangerous procedure (hemorrhage) Limited to case with left lobe hypertrophy

33. Combined modalities approach- Most strictures are managed by modalities described above With risk of recurrent strictures or stone formation High hepaticojejunostomy over trans- jejunal tube brought exterior across the blind end of roux limb

34. Defunctionalized roux limb left long and end is secured subcutaneously or subperitoneally This allows easy access for cholangiography , cholangioscopy , dilatation or stone removal Also the blind end of roux-en-Y limb may be re-accessed by percutaneous puncture under fluoroscopic guidance or small incision under local anesthesia for late diagnostic and therapeutic procedures long after transjejunal tube has been removed.

35. Nonoperative Approach Percutaneous balloon dilatation Multiple admissions Repeated interventions Overall costs and morbidity not much difference with operative procedures Operative procedure more effective and provides more durable relief Preferable in patients not tolerable to operations

36. References Surgery of Liver and Biliary tract- L.H Blumgart Sabiston Text book of surgery