Classifications of bile duct injury
(according to date of publication)
Bismuth Classification (1981/2) (13)
Type 1: low (distal) common hepatic (CHD) or main bile duct stricture (injury), with a
healthy stump of 2cm or more proximal to the lesion
Type 2: high (proximal) CHD stricture (injury), with < 2cm of healthy CHD proximal to
the lesion
Type 3: Hilar stricture, no remaining CHD structure but (superior) biliary confluence
preserved; preservation of communication between right and left ductal systems
Type 4: Hilar stricture, with involvement of superior confluence and loss of
communication between the right and left hepatic ducts
Type 5: involvement of aberrant right sectorial hepatic duct alone or with concomitant
stricture of the CHD
Type 6:
Siewert classification (1994)(10)
Type I: immediate biliary fistulae (cystic duct insufficiency)
Type II: Late strictures of main without obvious intraoperative trauma to the duct
Type III: tangential lesions without structural loss of the duct
a: with additional vascular injury
b: without additional vascular injury
Type IV: lesion with a structural defect of the hepatic or common bile duct
a: with additional vascular injury
b: without additional vascular injury
McMahon et al 1995 (8)
Major bile duct injury (at least one of the following):
Laceration > 25% of bile duct diameter sic (circumference)
Transection of CHD or common bile duct (CBD)
Development of post-operative bile duct stricture
Minor bile duct injury
Laceration <25% of bile duct diameter sic (circumference)
Laceration of cystic duct-CBD junction (buttonhole tear)
Strasberg classification (1995) (24)
Type A: bile leak from a minor duct still in continuity with the common bile duct i.e.
cystic duct leaks or leaks from small ducts in the liver bed
Type B: occlusion of part of the biliary tree, almost always involving an aberrant right
hepatic duct
Type C: bile leak not in communication with the main bile duct: i.e. transection
without ligation of an aberrant right hepatic duct
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Type D: Lateral injuries to extrahepatic major bile ducts
Type E: circumferential injury as per Bismuth
Connor and Garden (6) added the E6 injury to the Strasberg classification in 2006 to
describe complete excision of the extrahepatic (biliary) confluence.
Amsterdam Academic Medical Center classification (Bergman et al (1996)) (17)
Type A: cystic duct leaks or leakage from aberrant or peripheral hepatic radicles
Type B: major bile duct leaks with or without concomitant biliary strictures
Type C: bile duct stricture without bile leakage
Type D: complete transection of the duct with or without excision of some portion of
the biliary tree
Neuhaus classification (Neuhaus 2000) (9)
Type A: peripheral bile leak (in communication with the CBD)
Type A1: cystic duct leak
Type A2: bile leak from the liver bed
Type B: Occlusion of the CBD (or right respectively left hepatic duct, i.e. clip, ligation)
Type B1: incomplete
Type B2: complete
Type C: Lateral injury of the CBD
Type C1: small lesion (<5mm)
Type C2: extended lesion (>5mm)
Type D: Transection of the CBD (or hepatic duct not in communication with the CBD)
D1: without structural defect
D2: with structural defect
Type E: stenosis of the CBD
E1: CBD with short stenosis (<5 mm)
E2: CBD with long stenosis (>5 mm)
E3: confluence
E4: right hepatic duct or segmental duct
Csendes classification (2001) (20)
Type I: A small tear of the hepatic duct or right hepatic branch caused by dissection
with the hook or scissors during the dissection of Calot’s triangle
Type II: Lesions of the cysticocholedochal junction due to excessive traction, the use
of a Dormia catheter, section of the cystic duct very close or at the junction with the
CBD, or to a burning of the cysticocholedochal junction by electrocautery
Type III: A partial or complete section of the CBD
Type IV: resection of more than 10 mm of the CBD
Stewart-Way classification (2004) (11)
Class I:
-CBD mistaken for cystic duct, but recognized
-Cholangiogram incision in cystic duct extended into CBD
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Class II:
-Lateral damage to the CHD from cautery or clips placed on duct
-Often associated bleeding, poor visibility
Class III:
-CBD mistaken for cystic duct, not recognized
-CBD, CHD, or right or left hepatic ducts transected and/or resected
Class IV:
-right hepatic duct mistaken for cystic duct; right hepatic artery mistaken for
cystic artery; right hepatic duct and right hepatic artery transected
-Lateral damage to the right hepatic duct from cautery or clips placed on duct
Sandha et al (2004)(23)
Low-grade (LG) leaks: those identified after opacification of intrahepatic
radicals (extravasation of contrast material requires hyperpressure)
High grade (HG) leaks: those detected before radicular opacification
(spontaneous extravasation of contrast material)
Lau classification (2007) (15)
Type 1: leaks from cystic duct stump or small ducts in liver bed
Type 2: partial CBD/CHD wall injuries without (2A) or with (2B) tissue loss
Type 3: CBD/CHD transection without (3A) or with (3B) tissue loss
Type 4: right/left hepatic duct or sectorial duct injuries without (4A) or with (4B) tissue
loss
Type 5: bile duct injuries associated with vascular injuries
Hannover (Bektas) (2007) (16)
Type A: peripheral bile leak (with reconnection to the main bile duct system)
Type A1: cystic duct leak
Type A2: leak in the region of the gallbladder bed
Type B: Stenosis of the main bile duct (without injury, i.e. caused by a clip),
Type B1: incomplete
Type B2: complete
Type C : Tangential injury of the common bile duct
C1 : small punctiform lesion (<5mm)
C2 : extensive lesion (> 5mm) below the hepatic bifurcation
C3 : extensive lesion at the level of the hepatic bifurcation
C4 : extensive lesion above the hepatic bifurcation
With vascular lesions
d : right hepatic artery
e : left hepatic artery
p : propria hepatic artery
c : cystic artery
com : common hepatic artery
pv : portal vein
Type D : completely transected bile duct
Type D1 : without defect below the hepatic bifurcation
Type D2 : with defect below the hepatic bifurcation
Type D3 : at hepatic bifurcation level
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Type D4 : above hpeatic bifurcation (with or without defect)
With vascular lesions
d : right hepatic artery
e : left hepatic artery
p : propria hepatic artery
c : cystic artery
com : common hepatic artery
pv : portal vein
Type E: strictures of the main bile duct
E1: main bile duct short circular (<5 mm)
E2: main bile duct longitudinal (>5 mm)
E3: hepatic bifurcation
E4: right main bile duct/segmental bile duct
Kapoor (2008) (21)
B: bile leak (in drain/on aspiration: isotope scan, cholangiogram, ERC, MRC):
By: (bile leak “yes”) open duct
Bn: (bile leak “no”) ligated/clipped duct)
C: circumference involved:
Cf : full circumference (transection or excision)
Cp-partial circumference (clip, cautery, hole, excision)
Operative findings
D Duct injured:
Ds-significant duct (CBD, CHD, RHD, right sectorial or segmental duct)
Di-insignificant duct (cystic duct, subsegmental duct, subvesical duct)
'V' is added for associated vascular injury
Li classification (2010) (22)
According to the size and drainage territory of the injured duct,
Type 1: injury to the right anterior/posterior sectorial duct or any other
segmental duct, which drains at least one Couinaud segment
Type 2: injury to a minor biliary radical in the gallbladder fossa, i.e. injury to the
subvesical bile duct or the duct of Luschka, which is usually smaller than 1 mm in
diameter
Cannon et al (2011)(1)
Grade I: leaks from the cystic duct stump, duct of Luschka, or accessory right
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hepatic ducts;
Grade II: all other levels of injury from the common bile duct to the intrahepatic
ducts
Grade III: all combined vascular and biliary injuries
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