Introduction

Bile duct injury is nowadays a serious health problem. Most lesions occur during laparoscopic surgery which is a common tool among surgeons in current practice¹.

The first cholecystectomy was performed by Langebuch in 1882. In 1891, Sprengel described the first side-to-side choledochoduodenostomy after bile duct injury. One year later, Doyen described the end-to-end anastomosis of the bile duct to repair a totally sectioned common bile duct. In 1905, Kerh repaired two cases of bile duct injuries using end-to-end anastomosis without drainage of the duct².

Although not statistically significant, the incidence of bile duct injuries during laparoscopic cholecystectomy is twice more common than during an open procedure (0.6% vs. 0.3%)

The two most frequent scenarios are bile leak and bile duct obstruction. Most of bile duct injuries after laparoscopic cholecystectomy are recognized in the immediate postoperative period³. Many patients with this complication may require long and complex surgeries⁴.

The aim of this study is to report our experience in repairing bile duct injuries, and how we manage this complication. As our institution is a referral center in the province, our surgical volume is mostly represented by biliary surgery (65% of the total surgeries per year). We also analyzed morbidity and mortality related with the procedure, and the incidence of this condition in our institution.

Material and methods

We conducted a retrospective and descriptive study. The information was retrieved form the medical records of 19 patients 9 patients with bile duct injury hospitalized at the Hospital José Ramón Vidal in Corrientes, Argentina, between January 2011 and July 2019. The cohort was made up of seven men and 12 women (Figure 1) between 18 and 72 years. Bile duct injuries occurred during open surgery in 9 patients (47.36%) and during video-assisted laparoscopic procedures in 10 patients (52.63%) (Figure 2). All the cholecystectomies were scheduled procedures. No vascular lesions were reported. In five cases the injury occurred in our institution: three were identified during surgery and two of these were repaired within the same procedure. The remaining case required stent placement and endoscopic dilation. Two injuries were identified in the postoperative period: one was resolved by endoscopic retrograde cholangiopancreatography (ERCP) and the other patient required reconstructive surgery (hepaticojejunostomy). The other patients were transferred from other institutions of our province which lack surgeons with expertise in laparoscopic surgery. A previous repair was not attempted in any of these patients. The anatomy of the injury was evaluated with percutaneous transhepatic cholangiography (PTC) (Figure 3), magnetic resonance cholangiopancreatography (MRCP) and computed tomography angiography (CTA) (Figure 4) with vascular reconstruction of the hepatic hilum (Figure 5). The lesions were classified using the Strasberg classification (Figure 6).

Results

The results are summarized in Table 1. A Roux-en-Y hepaticojejunostomy (RYHJ) was performed in 12 patients, double hepaticojejunostomy in two patients, and two patients were treated with end-to-end ductal anastomosis with suture over a T tube (Figure 7). The anastomoses were performed intraoperatively in two cases of injuries that occurred in our institution. In the remaining patients, the procedures were performed between 6 and 8 weeks after the injury, using absorbable monofilament suture (polyglycolic acid 4-0). A transanastomotic drain was placed in three patients who underwent RYHJ through an orifice created at the antimesenteric side of the Roux-limb (Figure 8). All the reconstructions were made by open surgery via a right subcostal incision. Three of the patients undergoing surgery developed stenosis of the anastomosis, which was resolved by percutaneous balloon dilation in three sessions; one patient presented bleeding after the initial percutaneous drainage. Complications occurred in 26.3% of the patients and there were no deaths. The patients were referred to our institution between 10 and 60 days after cholecystectomy (mean 19.5 days). Eighteen patients (94.7%) developed jaundice. All the patients with percutaneous drainage or transanastomotic drainage underwent control cholangiography. The trasanastomotic drain was removed three months after surgery. All the patients were discharged with ursodeoxycholic acid (600 mg/day) and were followed-up and monitored with cholangiography and laboratory tests. Three patients underwent ERCP with stent placement and dilation. Stitches were removed 10 days after discharge. Follow-up visits were scheduled at 30 and 90 days, 6 months and once a year with laboratory tests and imaging tests, as applicable.

Discussion

Bile duct injury represents a serious health problem for patients and surgeons. Despite the experience gained with laparoscopic cholecystectomy, the incidence is 0.03-0,6% in most experienced centers⁵, and 0.08% in our institution⁶.

Anatomic anomalies, local pathology, and poor surgical techniques are the main causes⁷.

Anatomic factors include cystic duct anomalies (high or low insertion, short duct or parallel course of cystic duct with the common bile duct) sectoral duct anomalies (in 20% of the cases one of the sectoral duct join the common hepatic duct), intrahepatic gallbladder and vascular anomalies (accessory right hepatic artery). Local pathology includes acute cholecystitis, scleroatrophic cholecystitis, Mirizzi syndrome, chronic cholecystitis and frozen Calot’s triangle. Difficult in terms of technique includes casual attitude towards a “simple gallbladder”, improper placement of trocars, bulky and hanging falciform ligament, bulky quadrate lobe, exaggerated or inadequate use of clips to control bleeding, injudicious use of electro cautery in Calot’s triangle, surgeons’ experience and the learning curve effect⁸.

Hepaticojejunostomy is the preferred procedure for most bile duct injuries⁹.

We believe surgeons should be trained in minimally invasive surgical procedures before performing a new laparoscopic technique¹⁰.

There are several classification systems of bile duct injury¹¹.The Strasberg classification seems to be the most adequate and easiest to understand despite it does not describe additional vascular involvement. Classification of the injury is done with imaging tests as MRCP, PTC or ERCP³.

The management of a bile duct injury after cholecystectomy costs between 4.5 and 26 times the cost of an uncomplicated laparoscopic cholecystectomy, with significant impact on hospital costs^12,16,17.

Imaging tests are essential to establish the diagnosis, define the extent of the injury and plan an appropriate intervention. These tests include ultrasound (US), computed tomography (CT) scan, MRCP, ERCP, and PTC¹³.

The consequences of an iatrogenic lesion can be serious^14.15.

Several methods have been recommended to prevent bile duct injury after surgery: avoid the use of energy device to prevent heat dissection near the main bile duct, knowledge of bile duct anatomy, use of the infundibular technique, critical view of safety described by Strasberg and intraoperative cholangiography, among others¹⁸.

If the responsible surgeon is not qualified to repair the injury, he or she must place an external drain into the bile duct making the smallest dissection possible of the hepatic hilum. If the bile duct cannot be drained, several drains should be placed in the Morrison’s space and in the right parietocolic gutter and then the patient should be transferred^19,20.

In the United States, most bile duct injuries are repaired in the same institution and by the same surgeon²¹.

The surgical technique consists of resecting the fibrous tissue scars and inflammatory tissue around the common bile duct immediately after the stricture until reaching the normal mucosa of the duct, trying not to mobilize the ducts too much so as not to generate ischemia that will produce a new stenosis²².

The lack of experience of surgeons, inadequate equipment, patient’s body constitution, aberrant anatomy and inflammation are considered the main risk factors.

In conclusion, bile duct injury may be a common complication after conventional or laparoscopic cholecystectomy. There are many ways to prevent this complication. There are no reliable statistical data on the condition in our country. Among the several classification systems of bile duct injury, we believe that the Strasberg classification is the most useful.

Our institution has a training center in laparoscopic surgery for residents and continuous training for staff surgeons. Our residents’ training is progressive, and they perform increasingly complex procedures.

The main goal of cholecystectomy should be to avoid bile duct injury. Partial cholecystectomy and cholecystostomy should be considered as options in case of frozen or complex gallbladder hilum.

Our prevalence is similar to the one reported by the international literature; nevertheless, we are still working to reduce it. Our morbidity and mortality rate after bile duct repair is adequate.

In case of bile duct injury after cholecystectomy, the recommendation is to place a drain tube and then transfer the patient to a center with surgeons experienced in repairing this complication.