Iatrogenic bile duct injury: impact and management challenges

Figures & data

Figure 1 Stewart-Way classification of bile duct injuries.

Notes: Adapted with permission from Wolters Kluwer Health, Inc.: Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460–469.⁸ Copyright © 2003 Lippincott Williams & Wilkins, Inc. Available from: https://journals.lww.com/annalsofsurgery/Abstract/2003/04000/Causes_and_Prevention_of_Laparoscopic_Bile_Duct.4.aspx. The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Wolters Kluwer Health, Inc. Please contact [email protected] for further information.

Table 1 Bismuth and Strasberg classification

Bile duct injury	Bismuth	Strasberg
Cystic duct leak or leaks from small ducts in liver bed	–	A
Occlusion of an aberrant RHD	–	B
Leak from an aberrant RHD	–	C
Lateral injury to CBD (<50% circumference)	–	D
CHD stricture, stump >2 cm	Type I	E1
CHD stricture, stump <2 cm	Type II	E2
Hilar stricture with preserved biliary confluence	Type III	E3
Hilar stricture with involvement of confluence	Type IV	E4
Stricture to an aberrant RHD and to CHD	Type V	E5

Abbreviations: –, not applicable; RHD, right hepatic duct; CBD, common bile duct; CHD, common hepatic duct.

Table 2 Summary of proposed methods to prevent bile duct injuries

• Critical view of safety (CVS) method

• Infundibular technique

• Antegrade dissection

• Subtotal cholecystectomy

• Anatomic landmarks:

○ Rouviere’s sulcus

○ Calot’s node

○ B-SAFE method

• Intra-operative cholangiography (IOC)

• Laparoscopic ultrasound (LUS)

• Near-infrared fluorescent cholangiography (NIRF-C)

• Conversion to open surgery

Note: B-SAFE: B, bile duct; S, sulcus of Rouvière; A, hepatic artery; F, umbilical fissure; E, enteric/duodenum.

Figure 2 Intra-operative real-time identification of biliary structures with visible light (VL) on left and by fluorescence (NIRF-C) on right.

Note: Cystic duct (CD) running parallel to the common hepatic duct (CHD).
Abbreviation: NIRF-C, near-infrared fluorescent cholangiography.

Figure 3 (A) Axial three-dimensional MRCP sequence showing a small fluid collection in the gallbladder fossa (white arrow). (B) T1-weighted hepatobiliary acquisition (after gadoxetic acid injection) demonstrates opacification of the small fluid collection suggesting a biliary leak from the cystic duct.

Abbreviation: MRCP, magnetic resonance cholangio-pancreatography.

Figure 4 Trans-Kehr cholangiography after the positioning of T-tube to protect biliary anastomotic suture.

Notes: Normal cholangiogram showing opacification of the cystic duct, CBD, common hepatic duct, right and left hepatic ducts, and the duodenum. The biliary tree is free without strictures and there is no evidence of biliary leak.
Abbreviation: CBD, common bile duct.

Figure 5 A hepaticojejunostomy was performed for a stricture at biliary confluence after the positioning of T-tube.

WayLWStewartLGantertWCauses and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspectiveAnn Surg2003237446046912677139

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