Introduction:

The number of laparoscopic cholecystectomies have increased since its introduction in 19901, laparoscopic approach was associated with an almost tenfold increase in the incidence of bile duct injury compared with open cholecystectomy during initial period 2. Subsequently, the incidence of bile duct injury over the past 20 years has decreased as surgeons gained more experience with laparoscopic surgery 1. A large administrative database from New York reviewing over 156,000 laparoscopic cholecystectomies performed between 2005 and 2010 reported 125 bile duct injuries for an overall incidence of 0.08 percent 3.

Goal of operative management:

Goal of operative management is to establish biliary intestinal continuity with free flow of bile from liver to intestine. Aim should be to achieve healthy, vascular, wide duct to mucosa anastomosis. Anastomosis should be away from fibrosis. (Fig 1)

Basic principle of repair:

• First reoperative surgery should be the last surgery.
• Number of reoperations increases morbidity and chances of failure.
• Definitive repair performed by the same surgeon ought to have more chances of failure.
• HPB surgeon in tertiary care center must do repair.

When to repair:

Early repairs have been found to have more complications and more chances of failure. Delayed repairs are preferred due to better outcome.

When to place preoperative percutaneous catheter tube:

In difficult strictures like type IV it is prudent to place a silastic tube under USG and fluoroscopic guidance either on the day or day before surgery. It helps in identification on the table and can be left for long if anastomosis is found to be difficult.
Preoperative preparation:

Patient must be adequately prepared. Three important factors must be taken care off; correction of coagulopathy, patient must be free of infection and nutrition must be optimized.
A good preoperative cholangiogram is must and MRCP is preferred to other invasive cholangiograms.

Operative Technique:

Position – Supine with sand bag below right chest.
Incision - Right subcostal with midline extension.
Abdomen is opened and careful adhesiolysis is done to avoid any injury to viscera while entering the abdomen. Liver is mobilized and falciform ligament is divided.
Dissection is started from right to left in the sub hepatic space (virgin area). A combination of sharp and blunt dissection is used to avoid any injury to hepatic flexure and duodenum and tear the glissonian capsule. (Fig 2) Porta is approached from right side pushing duodenum down. Hilar plate is lowered using sharp dissection at the base of segment 4. Bipolar cautery is preferred here to avoid any injury. In the hilum duct lies superiorly and posteriorly to portal vein and using sharp and blunt dissection portal is pushed down. Fibro fatty tissue from gall bladder bed to the base of he segment four is dissected out using bipolar cautery. This exposes right duct at porta.

Identification of duct:

If preoperative percutaneous catheter is not placed duct can be identified by its anatomical location and color.
If repair is done in presence if fistula then fistulous opening could guide proximal duct.
If percutaneous catheter is place in the preoperative period it can be palpated to and duct may be identified.
Round ligament could be followed from left to right and duct can be located.
Some times clip or thick suture material may be used as guide.
Intraoperative ultrasound may be helpful in difficult situations.

Opening of the duct


Once duct is identified:

It is aspirated using 24f needle and its location is confirmed.
Two stay sutures are taken and duct is opened by no 11 knife lifting two preplaced sutures.
Opening is enlarged using Pott’s vascular scissors. Use of energy sources is avoided. Left limit of opening is left hepatic artery. Incision is extended toward right and opening of right duct is also confirmed.
It is mandatory to confirm that all blocked segments are opened and drained.
Sometimes a wedge of the hanging segment 4 is excised to get access to the duct and it makes anastomosis easier.
No attempt is made to search for the lower limit of the duct.
No attempt should be made to dissect around the duct it compromises the vascularity of the duct
Roux loop is prepared using third jejunal arcade (it is most mobile)

Anastomosis:

Anastomosis is done using Blumgart and Kelly’s technique.
Both angle sutures are taken first from inside out.
Some prefer preplaced anterior layer sutures from inside out (classical Blumgart technique) but we don’t use it routinely.
Posterior layer sutures are taken from left of the patient to the right depth and distance should not exceed 2.5 to 3 mm, interrupted sutures are taken and preplaced inside out in the jejunum and outside in towards bile duct.
Sutures are tightened from right to left of the patient and cut at the end
After posterior layer is complete, anterior layer is taken maintaining the same principle.
5-0 PDS is preferred suture material.
Continuous suturing may be done depending upon experience and competency of surgeon.
Routine stenting of the anastomosis is not done however if trans hepatic catheter is preplaced it should be passed across anastomosis should be taken out after doing cholangiogram.
A soft sub hepatic suction drain is put and abdomen is closed.




Reference:
1. Dolan JP, Diggs BS, Sheppard BC, Hunter JG. Ten-year trend in the national volume of bile duct injuries requiring operative repair. Surg Endosc 2005; 19:967.
2. McPartland KJ, Pomposelli JJ. Iatrogenic biliary injuries: classification, identification, and management. Surg Clin North Am 2008; 88:1329.
3. Halbert C, Altieri MS, Yang J, et al. Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy. Surg Endosc 2016; 30:4294.