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If IBDI other than class I are detected intraoperatively, there are two options. If a senior hepatobiliary surgeon is available, he or she should be called for immediate reconstruction. If not, drains can be placed (to evacuate bile) and the patient should be immediately referred to a tertiary center for further treatment. As already mentioned, repair by the primary surgeon is associated with less favorable outcomes, and sometimes the attempted repair can further damage the ducts and make subsequent reconstruction more difficult [48,49,50]. Surgeons should take into consideration the extent of injury as well as their own experience and skills in biliary surgery when determining the best approach for management of these biliary injuries.
Cystic duct leaks are well manageable; the treatment of choice is endoscopic retrograde cholangiopancreatography and sphincterotomy  or endoscopic stenting and drainage of intra-abdominal bile collections. Nearly all cystic duct leaks will close with this management scheme. It is crucial to drain bile collections; the stent only acts to decrease the pressure in the biliary tree and does neither cover the leak nor prevent bile drainage.
CHD = Common hepatic duct; RHD = right hepatic duct; CBD = common bile duct.
Several studies reported that the timing of biliary reconstruction influences the outcome; these series reported worse outcomes for biliary reconstructions performed within 6 weeks of injury [52,54,65]. Stewart and Way  examined this question, using multivariate analysis, and noted that the timing of repair was not an independent predictor of successful biliary repair. Instead, success correlated with eradication of intra-abdominal infection, complete preoperative cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. This timing issue most likely relates to the time required to eradicate intra-abdominal inflammation and to achieve nutritional repletion. In this series, good results were achieved with early biliary reconstruction in those patients with good nutrition, good functional status, and early control of intra-abdominal inflammation .
Specific Bile Duct Injuries
– bile duct injuries in patients with pre-existing chronic hepatic disease .
In the future, ultrasound and intraoperative fluorescence cholangiography may help to reduce IBDI. In this respect, near-infrared fluorescence cholangiography (NIRFC) was developed [32,33,34] and a multicenter randomized controlled trial is currently recruiting to compare NIRFC-assisted laparoscopic cholecystectomy with conventional laparoscopic cholecystectomy (FALCON trial) . When employing this method, intravenous injection of a dye (indocyanine green) and use of specific equipment, i.e. an NIR light-emitting xenon-based light source and a camera that is capable of detecting NIR fluorescence emitted by indocyanine green-dyed bile, is required . Neither the dye (at normal doses) nor the equipment is dangerous (no irradiation) for the patient or surgeon. Compared with IOC, NIRFC has been shown to be quicker to perform and to cost less ; however, an increased safety has yet to be proven. Theoretically, it should be possible to perform NIRFC in all cases (vs. a 93% rate for IOC) because of the impossibility to cannulate the cystic duct (which represents a dangerous risk factor!) [38,39].
Contrary to widespread opinion, the determination of serum alkaline phosphatase and total bilirubin in particular is not sensitive early in the initial postoperative course [43,44]. The majority of patients with IBDI will present within the first few weeks following the index operation [45,46]. The symptoms will be unspecific and may include fever, pain, and mild hyperbilirubinemia (2.5 mg/dl) from biloma or bile peritonitis . Biliary leakage will be suspected in the case of bile appearance from either percutaneous drainage of abdominal collection or abdominal drain placed at the time of cholecystectomy. In case of injuries involving occlusion of the CHD or CBD without an intraperitoneal bile leak, the main symptoms will be jaundice with or without abdominal pain. In some cases, patients will present with cholangitis or cirrhosis from remote IBDI at a later time, probably months or even years after biliary surgery . In severe early postoperative cases, patients will present with sepsis from cholangitis or intra-abdominal fluid collections. In the case of a suspected bile leak, ultrasound and/or an abdominal computed tomography (CT) scan will identify peritoneal fluid, biloma, or an abscess. In the case of perihepatic fluid collections, drainage can be applied percutaneously. Usually, broad-spectrum parenteral antibiotics covering the common biliary pathogens are initiated . When a percutaneous drainage is applied and ongoing biliary drainage is observed, an active bile leak is verified.
Timing of Biliary Reconstruction
– Class II injuries (24% of cases) consist of lateral damage to the hepatic duct by unintended application of clips or cautery. These injuries do usually occur when visibility is limited due to inflammation or bleeding. For one reason or another, the surgeon was working too deep in the triangle of Calot, unknowingly close to the common hepatic duct (CHD).
Cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery, and the laparoscopic approach is now the gold standard for symptomatic cholecystolithiasis as well as for chronic and acute cholecystitis . Besides the advantages of a distinctly faster recovery and better cosmetic results, the laparoscopic approach bears a higher risk for iatrogenic bile duct injury (IBDI) and injury of the (right) hepatic artery. IBDI is a complication associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation . Despite increasing experience and progress in laparoscopic skills of surgeons, the incidence of IBDI is still elevated compared to open cholecystectomy . The rate of clinically relevant bile leaks after conventional open cholecystectomy ranges between 0.1 and 0.5% [3,4,5,6]. In contrast, biliary leakages have increased in the era of laparoscopic cholecystectomy (LC) by up to 3% [7,8,9,10]. A variety of injuries can occur. Besides minor bile leakage of aberrant ducts, cystic stump or the main bile duct, complete occlusion of the main duct or a branch (often an aberrant right duct) can happen. In addition, bile duct strictures and biliary leakages are severe long-term complications after LC. These injuries are associated with high morbidity, mortality, and prolonged hospitalization . Currently, endoscopic procedures are most frequently used in the management of postoperative IBDI. There are several endoscopic techniques available, e.g. biliary stent placement, biliary sphincterotomy, and nasobiliary drainage [12,13,14]. In this respect, endoscopic therapy can reduce the transpapillary pressure gradient and improve the transpapillary flow, which decreases the extravasation out of the biliary tract. This reduction of bile leakage allows healing of duct lesion injuries without direct surgical repair. Nonetheless, if major IBDI occurs, i.e. complete dissection of the common bile duct (CBD), surgical management is required to resolve this issue . In an effort to reduce further complications and injuries in the hepatoduodenal ligament, surgical procedures should be performed in collaboration with skilled and experienced hepatobiliary surgeons, interventional radiologists, and gastroenterologists at a tertiary referral center [16,17].
A total of 565 of the 1,661 (34%) respondents reported 704 biliary tract injuries. In group A, 422 of 1,122 (38%) respondents reported 533 injuries; in group B, 143 of 539 (26%) respondents reported 171 biliary tract injuries (P = .05) (see Table 1 ). Only one bile duct injury was reported by 447 (79%) surgeons: 329 (78%) from group A and 118 (82%) from group B. More than one injury was reported by 118 (21.9%) respondents ( Fig. 1 ): 75 (17%) surgeons in group A and 22 (15.3%) surgeons in group B reported two injuries, 17 (4%) surgeons in group A and 3 (<1%) surgeons in group B reported three injuries, and 1 surgeon in group A reported four injuries. A conditional mean was calculated to determine the mean number of injuries per surgeon for those surgeons in both groups who reported at least one injury. The mean number of injuries per surgeon for surgeons reporting at least one injury was 1.3 ± 0.5 for group A and 1.2 ± 0.4 for group B (P = NS).
Table 7. DETECTION OF BILE DUCT INJURY AS INFLUENCE BY TYPE OF OPERATIVE CHOLANGIOGRAM AND STUDY GROUP
Location of the injury along the biliary tree
The authors thank Cyndi Lyon and Ramaz Metrovelli, MD, for help with distribution of the questionnaire. Also, the authors acknowledge the endosurgery fellows who made up the USSC Bile Duct Collaborative Group and who aided in study design and in data collection: Brent Matthews, MD, Ed Chekan, MD, Amjad Ali, MD, Scot Roth, MD, Larry Damore, MD, Omar Bholat, MD, Daniel Scott, MD, Renee Wolff, MD, Dieter Pohl, MD, and Christina Richards, MD.
Anatomy and Treatment of Injuries
Whether a cholangiogram was completed during a case in which an injury occurred