Biliary injury management – Principles

Biliary injury is one of the most dreaded complications of laparoscopic cholecystectomy. We have one of the most experienced surgeons who has managed more than 70 cases of biliary injuries referred to him. So, this talk highlights the basics of mechanisms of biliary injury as well as the principles of management of biliary injury. This is one of the talks of our third webinar on “safe laparoscopic cholecystectomy and management of biliary injuries”

As can be seen from the talk, the mechanism of injury can be due to anatomical variations that are not properly identified during the surgery or preoperatively, or due to excessive traction on the fundus of the gallbladder which tenses the common bile duct, or a difficult case with excessive adhesions and frozen calot’s triangle where aggressive attempts are made to achieve the critical view of safety.

After discussing the mechanism of injury with the help of schematics, the talk then focuses on the basics of Management and answers how you can approach a patient with a biliary injury. If identified intraoperatively, the key point is to call your colleague or a senior to be there during the repair surgery even if you are a hepatobiliary surgeon yourself. This is because when the injury happens, there are a lot of emotional and anxiety-related issues in the surgery for the primary surgeon which can affect the decision making.

Intraoperatively if you are sure that there is no vascular injury, you can attempt repair of the biliary injury. However, most cases are detected postoperatively. The key points include stabilization of the patient and clearing of sepsis if the injury is identified postoperatively. This can be followed by appropriate imaging which can include CT scan for collections and drainage of collections, MRCP for biliary anatomy, HIDA scan for knowing the site of the leak, and occasionally ERCP or PTC which may be diagnostic as well as therapeutic in some cases.

Once these investigations are carried out, we would come to know the site of the injury and its classification. The Strasberg classification is most commonly used. Based on this classification, the injury can be managed in different ways surgically depending on the timing of detection. A separate discussion for early versus delayed repair for biliary injury follows this talk in the webinar and hence this is not touched in detail in the current talk.

The different surgical options are then discussed. Repair over T tube, hepaticojejunostomy, and choledochoduodenostomy are enumerated and each of these has been discussed. Another key point is to not forget the assessment of vascular injury before taking the patient in for repair.

As discussed at the end of the topic it is always prudent to call your colleagues, friend, or a senior surgeon for help. As mentioned in the talk, the first repair is the best repair and if the first repair fails, the patient is bound to have multiple attempts at repair.