The implications and management of complex biliary injuries at a tertiary hepatobiliary specialty center.

Injuries of the biliary tract and complex injuries involving vascular and parenchymal tissue can be detrimental despite the improved use of laparoscopy. Complex biliary injuries are variable depending on the type of injury as well as patient and surgeon factors. We present four cases of complex biliary injuries at our tertiary referral center with hepatobiliary expertise: biliary stenosis with obstruction, double duct system anatomy, combined right hepatic arterial transection and biliary duct injury, and a complete pedicle injury. Early identification and specialized repair of complex biliary injuries is essential to minimize patient morbidity. Notably, consulting a specialist intraoperatively in case of difficult dissection and visualization or a suspected injury and considering bail-out strategies such as a subtotal cholecystectomy or conversion are safe approaches to minimize complex biliary injuries. Earlier recognition and repair of complex biliary injuries improves outcomes when immediate intraoperative repair can be performed rather than delayed postoperatively.

Introduction

Biliary tract injuries are an uncommon complication of upper GI surgeries, with an incidence ranging between 0.5% and 1.5% of laparoscopic cholecystectomies in recent studies.[1,2] Nevertheless, when encountered, these injuries are severely detrimental and vary depending on the injury and patient and provider factors, and suboptimal management may propagate biliary damage and patient morbidity.

Most commonly, the common bile duct (CBD) is mistaken for the cystic duct, resulting in clipping and division of the CBD. Strasberg delineates multiple mechanisms of biliary injuries, such partial occlusion of the biliary tree, most likely of an aberrant right hepatic duct, or circumferential injuries. Common factors contributing to biliary injuries include inflammation of the porta hepatis, variable portal anatomy, aggressive attempts at hemostasis, cauterization, blind clipping, and difficult vascular identification.[3,4] This can often result in strictures and concomitant vascular injuries.

Vascular injuries may lead to complications due to resulting ischemia of the liver parenchyma and the biliary tree, atrophy, necrosis, and abscess or stricture formation.[5,6] Moreover, vascular injuries render reconstruction more difficult, with poor prognosis associated with vascular and parenchymal injuries when performed at centers that lack hepato-pancreato-biliary (HPB) expertise.

The literature describes the management approaches to biliary injuries, guided by the various classifications of bile duct injuries such as the Corlette-Bismuth, Strasberg, and the more recent Stewart-Way classification, which incorporates vascular injury patterns.[3,4] Nevertheless, biliary injuries are variable, and management is best tailored to a case-by-case basis to avoid serious, detrimental complications.[5-7]

Our tertiary healthcare center is a referral center that has encountered more than 100 biliary injuries to date. Most of these injuries have been discussed in the literature. We selected cases that we deemed rarely encountered, unique, or difficult to manage, with aims of contributing expertise management strategies to cases that may be minimally discussed, since understanding the impact of rare yet complex biliary injuries (CBI) and their efficient management is thus crucial to attain optimal patient outcomes when these injuries are encountered. We describe four cases of CBI examined retrospectively and discuss their etiologies, impact, and management approach at our center. The reported cases are in-line with the SCARE and PROCESS guidelines.[8,9]

Case presentations

Case 1

A 30-year-old male patient with a history of cholelithiasis presented to our tertiary academic healthcare center’s emergency department (ED) with postprandial right upper quadrant abdominal pain. He had previously presented with biliary lithiasis at another rural hospital where several attempts at biliary stenting with endoscopic retrograde cholangiopancreatography (ERCP) had failed; he then underwent an exploratory laparotomy during which gallbladder visualization was deemed difficult and thus involved extensive CBD exploration and hepatic manipulation requiring insertion of a hepatic drain, cholecystostomy tube, and subhepatic Penrose drain. Few weeks later, the patient developed CBD stenosis and haemobilia for which he underwent hepatic artery stenting and was then referred to our center.

CT abdomen performed in our ED revealed a dilated biliary tree and a coil in the hepatic artery. Percutaneous cholangiography (PTC) demonstrated bile drainage into a collection with a CBD stricture and biliary drains out of place (Figure 1). The decision was to pursue surgery to relieve the collection and stenosis. Intraoperatively, left hepatic lobe and CBD necrosis were noted. We performed a left hepatectomy with Roux-en-Y hepaticojejunostomy (RYHJ) and inserted a biliary drain. Postoperatively, the patient was observed in the hospital for several days with no complications noted and his pain subsided. The patient was discharged in a stable condition and had no complaints at subsequent follow-up visits in clinic every few weeks.

Figure 1.

Trans-hepatic PTC reveals a stricture at the distal left biliary duct with bile draining into a collection adjacent to the proximal duodenum and severe narrowing of the second part of the duodenum.

Case 2

A 31-year-old female patient with a history of cholelithiasis was referred to our specialty hepatobiliary clinic from a peripheral hospital. Two weeks prior to presentation, she had undergone a laparoscopic cholecystectomy for symptomatic gallstones. Ten days after the surgery, she started experiencing right upper quadrant pain, fever, and jaundice. Subsequent ERCP showed complete blockage of the bile duct about 5 cm from the Sphincter of Oddi with proximal dilatation.

We performed an exploratory laparotomy, which revealed patchy areas of ischemia over the right hepatic lobe. One clip was found toward the bifurcation of the cystic duct with the common hepatic duct and another below it was obliterating part of the common hepatic duct (Figure 2). We dissected the porta hepatis and the common hepatic duct. The left hepatic artery was intact whereas the right hepatic artery was completely divided and clipped. We proceeded with hepatic artery reconstruction and Roux-en-Y hepaticojejunostomy (RYHJ) where the bile duct was divided proximally at the level of the confluence and both right and left hepatic ducts were sutured to the same anastomosis. The patient had a smooth hospital course and was discharged home after few days with no intraoperative or postoperative complications. The patient was seen in clinic several weeks later with no complaints.

Figure 2.

Clip locations noted in Case 2: (a) Toward the bifurcation of the cystic duct with the common hepatic duct, (b) obliterating part of the hepatic duct, and (c) completely transecting the right hepatic artery.

Case 3

A 45-year-old female patient with a history of cholelithiasis presented to our ED with high-grade fever and severe abdominal pain. She had undergone a laparoscopic cholecystectomy at a peripheral hospital for symptomatic gallstones a few days prior to presenting, after which a CT scan demonstrated perihepatic and perisplenic fluid in the abdomen. Percutaneous drainage was attempted at the time and revealed bilious fluid. In light of her critical condition, she was referred to our center.

We performed an exploratory laparotomy and an intraoperative cholangiogram (IOC) which showed an intact biliary tree with no evidence of bile leak (Figure 3). Exploration of the porta hepatis revealed a second CBD with a transected lumen that was draining bile (Figure 4). A second cholangiogram was performed intraoperatively through that lumen and revealed an intact intrahepatic biliary duct (Figure 5). RYHJ was finally performed. The patient had a smooth hospital course over several days with no postoperative complications or complaints at multiple follow-up visits.

Figure 3.

Intraoperative cholangiogram through the cystic duct stump.

Figure 4.

Transected double cystic duct lumen identified during exploration of the porta hepatis (pointed at by the forceps).

Figure 5.

IOC done through the transected lumen identified during exploration of the porta hepatis.

Case 4

A 50-year-old male patient was transferred to our intensive care unit (ICU) from a remote hospital after an open cholecystectomy. He had developed a massive bleed at the portal vein due to a retraction injury, and intraoperative control had led to more damage. The patient was unstable and in disseminated intravascular coagulation (DIC).

Surgery was performed, and a complete pedicle injury was identified (Figure 6). We mobilized and performed end-to-end anastomosis of the distal splenic vein and hepatic artery to the hepatic bed to restore blood flow through the hepatic vein and proximal hepatic artery, respectively. The patient’s status was critical; thus, the repair of the bile duct injury was completed at a second stage after stabilization. This two-stage procedure was effective at restoring biliary drainage and blood flow at the level of the pedicle after a complete injury. The patient tolerated both procedures well with no complications observed during his hospital stay and at follow-ups.

Figure 6.

Complete pedicle injury with complete transection of the hepatic duct along with the portal vein and hepatic artery.

Discussion

Biliary stenosis with obstruction

The recommended management of biliary stenosis is endoscopic balloon insertion or stenting which are often reported to have high success rates at almost 90%.[4,10,11] The second-line approach is percutaneous biloma drainage, which is a temporary palliative option. RYHJ can be considered next, especially in the case of complete transection and complex problems.

Our first patient experienced a bile duct injury after an exploratory laparotomy and an associated hepatic artery injury. Difficult visualization of the vasculobiliary system and blind repair may have contributed to this patient’s initial injury. Moreover, attempts at mitigating the resulting postoperative complication of hemobilia through hepatic artery stenting may have further contributed to CBI as well as liver and CBD necrosis. A series of injuries and repairs may result in accumulated injuries that ensue persistent patient deterioration; it is thus necessary to target the most optimal and safe approach as early as possible. Moreover, prompt repair of biliary strictures is critical to avoid detrimental long-term sequelae including cholangitis or perforation.

RYHJ was our initial approach for this patient as neither stent placement nor percutaneous biloma drainage alone would target all complications seen in this patient. Time to surgery is an essential concept in the management of biliary injuries, especially those with complex vascular complications. Although our patient was stable, it is essential to recognize and consider the multiple associated complications to proceed with the best first management approach for each patient.

Combined right hepatic arterial transection and biliary duct injury

When a bile duct is completely transected, two short segments can be approximated with an end-to-end anastomosis; however, this is typically associated with strictures and subsequent complications and low success rates. With extensive biliary duct and vascular injuries, RYHJ may be the optimal option.

Inadvertent clipping during cholecystectomy is a common phenomenon that leads to biliary injury that can obstruct the CBD. Clipping of the vascular bed may lead to parenchymal compromise, as demonstrated in our second patient who experienced complete right hepatic artery transection leading to right hepatic lobe necrosis in addition to CBD stricture. This injury combination is not delineated as part of the established classifications, and the management is minimally discussed. It is essential to recognize the various injury combinations that could arise to best manage these patients.

Multiple complex injuries at several locations increase the repair time and make surgical repair more difficult with friable, injured tissue. Care must be taken to inspect the intraoperative field for injuries located in the triangle of Calot, but also at the proximal hepatic arteries in the porta hepatis. Early inspection and identification may spare further complications and the morbidity associated with repeat reparative surgery.

Double duct system anatomy

Double duct systems are a rare congenital anatomical duplication of the biliary tree. Both cholangiograms in our third patient identified two different routes for biliary drainage. It is likely that the transected duct was also draining into the gallbladder, which is a rare, undescribed anomaly.

A double duct system can make biliary surgery more delicate as care should be taken to avoid injuries at multiple sites. This may also make biliary injuries more morbid for patients and make repairs more challenging, especially with the possibility of mistaking either of the CBDs as a cystic duct if the diagnosis is not realized prior to surgery. Preoperative recognition of double duct systems prevents unpreparedness in case of intraoperative identification of this anomaly or inadvertent injury prior to IOC. Some cases may be identified through ultrasound imaging. Nevertheless, if unidentified preoperatively, intraoperative caution with dissection alongside IOC is necessary to avoid iatrogenic biliary duct injuries especially with multiple ducts. An awareness of this anomaly and exercised caution with surgical technique may mitigate patient morbidity if double duct systems are encountered.

Complete pedicle injury

Injuries involving the vasculobiliary sheath can be performed without liver dissection by approaching the hepatic hilus but may be unsafe due to hazardous dissections with anatomical variations. Various bypass and shunting procedures for the repair of juxtahepatic venous injuries have been associated with vascular injury, thrombosis, and emboli. Our fourth patient with a complete pedicle injury presented to us in a critical state. A series of end-to-end anastomoses in the context of complete vasculobiliary transection in a two-stage procedure that prioritizes vascular repair can minimize procedural complications and patient morbidity. This is in comparison with primary repair or simultaneous vascular and biliary repair which we deem to demand more operative time and increase morbidity and mortality rates. Moreover, vascular injuries should be promptly addressed in order to reduce rates of liver and CBD infarction and necrosis, as well as the detrimental complication of biliary strictures. Thus far, our patient did not experience subsequent manifestations of vascular injuries or thromboembolic events following the described approach.

An overview of CBI

Despite a smooth postoperative course, all our patients required prolonged hospital admission. In addition, some patients needed ICU admissions due to their critical presentation. All four patients progressively experienced symptomatic improvement and clinical stability after CBI repair. Early identification and specialized repair of CBI is thus essential to reduce grave postoperative outcomes. Blind attempts at repair, especially with little experience and proficiency, may often pose more harm than benefit, and it is essential to consider intraoperative specialist consultation in case of a suspected injury during HPB surgery, especially with CBI. All our procedures were performed by an experienced, trained hepatobiliary specialty surgeon.

Importantly, prevention of CBI is optimal. Identification of the critical view of safety (CVS) is an essential step of every cholecystectomy to avoid vasculobiliary injuries. In case intraoperative difficulty is encountered laparoscopically or the CVS is not discerned due to extensive fibrosis or obscuring inflammation, bail-out strategies such as a subtotal cholecystectomy is recognized as a safe approach. Awareness that “conversion is not crime” must also be raised. An open approach may even ease dissection while minimizing injuries attributed to depth perception or laparoscopic skills. Even so, careful inspection of the surgical field must be performed after completion of the surgery, since earlier recognition and repair of CBI improves outcomes when immediate intraoperative repair can be performed rather than delayed postoperatively.

Conclusion

Prevention of CBI through improved perioperative injury recognition, intraoperative skills, awareness of the management approaches for variable presentations of injuries, consulting specialists intraoperatively, and considering conversion are essential to reduce CBI rates. Understanding that early recognition and repair is key to minimizing morbidity from CBI even if encountered is essential to improving patient quality of life after a cholecystectomy.