Section: Hepatobiliary Sub-section: Biliary Curriculum: Curriculum, page 89

Aetiology

Mostly lap chole
Primary cause – visual perceptual illusion (97%), technical (3%)
Occasionally abdominal trauma, injection of scolicidal agent for hydatid cyst, ablation of hepatic tumours or radiotherapy.

Techniques to avoid injury

Cholecystectomy
Correct identification of biliary anatomy
Dissection at correct level – junction of gallbladder and cystic duct, staying close to gallbladder.
Structures traced into gallbladder
Critical view of safety
Avoiding diathermy in Calot’s triangle. Avoid blind cauterising or clipping of arterial bleeding.
Connor et al. five-point checklist
- Confirm gallbladder lies in the hepatic principal plane and is retracted to 10 o’clock position
- Confirm Hartmann’s pouch is lifted up and toward the segment IV pedicle
- Identify Rouviere’s sulcus
- Confirm the release of the posterior left of the peritoneum covering the hepatobiliary triangle.
- Confirm the critical view
IOC
- Reduction in biliary injuries when used routinely
- Correct IOC interpretation involves:
  - Duodenal flow
  - Proximal filling of the common bile duct
  - Three proximal hepatic ducts (right anterior, posterior sectoral and left main ducts)
  - Absence of filling defects within the common bile duct
  - The presence of spiral valves within the cystic duct
Subtotal or opening gallbladder.

Best recognised at time of surgery (<1/3)
Early post-op
- Biliary fistula
- Biliary peritonitis
- Jaundice
- Symptoms of peritoneal or diaphragmatic irrigation or associated LFT derangement.
Late post-op
- Presentation may be stricture due to partial injury, localised inflammation or ischaemic insult
- Ligation of sectoral ducts may cause late atrophy of the drained liver segments which may become infected secondarily.
  - Occasionally liver resection or transplant may be required. May have late liver failure due to secondary biliary cirrhosis.

Should be referred to experienced surgeon immediately.
- Success of repair by initial surgeon is unlikely.
If help unavailable, cholangiogram if possible to understand anatomy, T-tube or similar drain placed and drains left in subhepatic space.
Complete transection should not be attempted to repair
Partial injury can be closed directly with placement of T-tube through separate choledochotomy.

If not fit for discharge at 24 hours due to abdo pain, vomiting, fever or bile in drain should be considered to have a biliary leak.
CT better than USS – more objective information and allows assessment of liver vasculature.
Laparoscopy – visualise source of bile leak. If cystic duct clips dislodged, can apply further clips or suture. However, any other source should be specialist referral.
ERCP allows anatomical definition, sphincterotomy or stent placement.
CT IV cholangiogram or MRCP can determine continuity of biliary tree prior to endoscopy (CBD transection precludes ERCP).
PTC
- May be required if ERCP unsuccessful or bile duct ligated.
- Can decompress biliary system

Ligation or clipping of biliary tree presents early with jaundice.
If stricture formation, may present later.
If diagnosis of ductal obstruction made within first week postop and only moderately elevated bilirubin with no coexisting coagulopathy or sepsis, immediate repair is best chance of success.
USS may indicate level of obstruction or exclude presence of retained stone
CT IVC not indicated as contrast agent not excreted.
MRCP will identify stricture or transection.
ERCP will also identify stricture or transection.
- Stent placed only after consultation with specialist unit – undrained biliary tree may allow proximal biliary dilatation facilitating later reconstruction.
Endoscopic stent or balloon dilation may be beneficial but usually short duration
- Indications – sepsis, severe itch or significant hepatic dysfunction

Ideally at the time or soon within 48h.
Early repair
- If recognised early with minimal peritoneal contamination, definitive repair by experienced surgeon can be successful.
Delayed repair
- 1^st priority is drainage of biliary sepsis
- CT required to ensure resolution of intraabdominal collections and exclude liver atrophy. Atrophy may be due to prolonged obstruction or presence of vascular injury.
- Once recovered and nutritionally optimised, can consider repair in 2-3 months.

Right subcostal incision.
Retraction with Omni-Tract®.
Injuries involving separation of confluence, can anastomose right and left together before formation of hepatojejunostomy.
For isolated right sectoral duct, best repaired or drained into Roux limb of jejunum.
- 70 cm Roux limb, with fine absorbable interrupted sutures 4/0 or 5/0 PDS, end to side.
Hepatoduodenostomy prone to enteric reflux.
If no recognisable bile ducts visible in porta hepatis, variation of portoenterostomy (Kasai procedure) can be considered with Roux limb sutured to fibrous structure of the hilar plate.
Partial injury can be repaired with fine interrupted sutures although if diathermy injury, formal hepato-jejunostomy may be necessary as thermal injury may cause later stricture formation.

If primary repair fails, usually from stricture, may need Roux-en-Y hepaticojejunostomy
Major vascular injury or unrecognised segmental biliary obstruction may lead to atrophy of liver, chronic intrahepatic infection, abscess formation or secondary biliary cirrhosis.
CT should be done to identify associated areas of liver atrophy and exclude portal vein thrombosis.
If ongoing sepsis or drainage of extrahepatic biliary tree not possible due to sectoral duct damage or fibrosis, may need liver resection.
Failed reconstruction and persistent cholangitis may lead to end-stage liver failure.