Yemeni-Turkish Surgical Congress,
30-31 May 2012, Sana’a
Surgical management of bile duct injuries
Sinan YOL, M.D.
General & Gastrointestinal Surgeon
Aim of the laparoscopic
cholecystectomy
• Surgey (TODAY)
Uncomplicated
Work (NEXT WEEK)
Aim of the laparoscopic
cholecystectomy
Surgery (TODAY)
Complicated / Injury
Long hospital stay
Repeated investigations like USG and ERCP
Radiologic interventions
Re-operations
Even liver transplantation
Bile duct injury
• Prevention should be the main point
(much more important than the treatment)
• ALL laparoscopic cholecystectomies ARE difficult!
– None of them is easy!
• If injury occurred, …
who should treat it?
when should it be treated?
how should it be treated?
Bile duct injury
classification (bismuth ve strasberg)
Treatment
If possible, diagnose the injury during the surgery!
When you realised that there is an injury, ASK for HELP!
If possible do not try to repair, even you are experienced.
An experienced and FRESH surgeon should repair the injury.
If it is impossible AND it is a difficult injury that you can not
treat, place catheters and refer the patient.
Intraoperative repair
Conversion! We do not like and do laparoscopic repair, if it is
not so simple.
There is no ‘Tissue Lost’, primary repair over T-tube???
stricture rate is high!!!
There is ‘Tissue Lost’, biliodigestive anastomosis:
choledocoduodenostomy / hepaticojejunostomy
Intraoperative repair
Intraoperative repair
How long you should keep the T-tube?
Previously it was 6 months to 1 year.
Now, after 2 or 3 week, we do ERCP and place
plastic stents (if possible more than one).
Post-operative diagnosed injury
Operation detail is important.
It is very common that each surgeon says there was an anomali
which is not true.
Variations:
Post-operative diagnosed injury
Real anomali
Post-operative diagnosed injury
Biliary leak OR obstruction (type of injury)
Physical examination (treat the patient, not laboratory values!)
There is bilioma / sepsis or not
accompanying injury?
Post-operative diagnosed injury
First control the leak (percutaneous catheter placement, relaparoscopic drainage, open surgery, nasobiliary drainage
etc.) and treat the peritonitis (or even sepsis).
If the fistula is under control, give time for inflammation.
Then try to diagnose the type of injury (MRCP, fistulography,
ERCP, PTC)
Diagnose
Diagnose
40 y old, female
Preoperative lab values N
POD 3, Bilirubin increased
USG minimal dilated bile duct
EndoUSG : choledocholithiasis
ERCP : stone extirpated
Diagnose
Leak from ductus cysticus
(Strasberg A)
Diagnose and treatment
Leak from ductus cysticus
(Strasberg A)
Nasobiliary drainage
Diagnose
ERCP
Complete obstruction
Diagnose
PTC (Strasberg E2)
Diagnose
MRCP
(Strasberg E3)
Diagnose
Arteriography
(RHA injury)
Surgical repair
Choledocho-choledochostomy
Surgical repair
Choledocho-duodenostomy
Surgical repair
Hepatico-jejunostomy (Roux-en-Y)
Surgical repair
Double lumen hepatico-jejunostomy (Roux-en-Y)
Surgical repair
Formation of one anastomosis
Surgical repair
left hepatic duct anastomosis
(Segment III / Hepp-Couinaud)
Surgical repair
Intrahepatic cholanjio-jejunostomy (Longmire)
Surgical repair
Permanent access hepatico-jejunostomy
Percutaneous repair
Endoscopy through permanent access
Percutaneous baloon dilation
Surgical repair
Fistulo-jejunostomy
Simple and short duration
surgery for selected patients