Biliary Injury and Laparoscopic Cholecystectomy

Posted by e-Medical PPT Saturday, May 5, 2012
Causes of Biliary Injury in Laparoscopic Cholecystectomy
Failure to properly occl. the cystic duct
Injury to the ducts in the liver bed caused by entering a plane too deep to the gallbladder
Cautery Misuse – thermal necrosisductal tissue loss
Pulling forcefully up on the gallbladder when clipping the cystic duct  tenting injury to the junction of the CBD & common hepatic duct

Strasberg & Soper classificaiton of bile duct injuries
Type A – bile leak from minor duct still in continuity w/ the CBD…cystic duct or liver bed
Type B – occlusion of part of the biliary tree; ex. Result of an injury to an aberrant right hepatic duct. 
Type C – leak from duct NOT in communication w/ CBD
Type D – lateral injury to extra-hepatic bile duct
Type E – circumferential injury

Diagnosis of Bile Leaks
Persistent fullness, anorexia, abdominal pain, fever & tenderness,jaundice,  elev WBC
High level of  suspicion following surgery
Bile draining from a drain left in the operative field

Radiographic Diagnosis of Biliary Injury
US/CT – detect bilomas (poss. perc drainage)
HIDA – presence of active bile leak (physiologic)
MRCP – demonstrate dilated/stenotic biliary tract; retained stones…..not physiologic nor therapeutic

ERCP
Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree.
Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site;  may entail removal of retained stone or internal stenting +/- sphincterotomy

Percutaneous Transhepatic Cholangiography
Another method of non-surgical Mx of bile leak
Usually reserved for when ERCP unsuccessful; since bile ducts of normal caliber increasing the difficulty of the procedure

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