Biliary injuries as a result of blunt and penetrating trauma.

Although rare in even the busiest trauma centers, lacerations, transections, or avulsions of the extrahepatic biliary ducts occur in patients who have experienced both blunt and penetrating abdominal trauma. The diagnosis is difficult in the patient undergoing observation only after blunt abdominal trauma and may not be made for several weeks. Ductal injuries have also been missed at operation in patients with associated injuries to the hilum of the liver or pancreatoduodenal complex. Scanning with HIDA, endoscopic retrograde cholangiography, and intraoperative cholangiography has been useful in detecting occult ductal injuries. The technique of repair in stable patients depends primarily on the location and extent of the ductal injury and has ranged from lateral choledochorrhaphy with absorbable sutures to biliary enteric bypass. T tubes or stents are frequently used because of the small size of the ductal system, although no agreement exists on how long they should remain in place after operation. Results of biliary enteric bypass operations for complex injuries are excellent as long as the tenuous blood supply of the bile duct is preserved and the anastomosis is tension free.