RECENT TRENDS IN MANAGEMENT OF BILIARY INJURIES AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Abstract

The management of patients following major bile duct injury is a surgical challenge often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. Collaboration among surgeons, gastroenterologists and interventional radiologists is imperative in the care of such injuries. Bile duct injuries can be traced to one of five errors: the wrong duct is ligated or transected or the lumen of the bile duct is occluded during flush ligation of the cystic duct or the blood supply to the common duct is compromised by excessive dissection or the lumen of the duct is traumatized by forceful dilatation or application and control of an energy source are inappropriate. Different IBDI classifications are described. The Bismuth classification, based on the era of open cholecystectomy, is the most useful in a clinical practice. It is based on location of the injury in the biliary tract. This classification is very helpful in prognosis after repair, but does not involve the wide spectrum of possible biliary injuries. The another classification is the Strasberg scale which, in difference from the Bismuth scale, allows to distinguish small (bile leakage from the cystic duct) and serious injuries performed during laparoscopic cholecystectomy, but it does not play an important role in choice of surgical treatment method. There are several other IBDI classifications performed during cholecystectomy (Steward and Way, Neuhaus, Csendes and Cannon). Early presentation occurs within days to weeks of initial operation. Patients presented by jaundice with progressively abnormal liver function tests. Late presentation occurs within months to years after the initial operation. Patients presented with episodes of cholangitis. Lastly manifestations of complications: secondary biliary cirrhosis, portal hypertension with bleeding varices and ascites may develop. Advancement of early diagnosis represents the corner stone of management including: laboratory investigations, radiological investigations (ultrasonography, computerized axial tomography, fistulogram, percutaneous transhepatic cholangiography, endoscopic retrograde cholongiopancreato-graphy, isotope scanning and future investigation intraoperative near-infrared fluorescent cholangiography). Management of bile duct injuries depends on several factors including; timing of detection of the injury and its extension, the general condition of the patient and experience of the surgeon in this field. Early detection and repair of bile duct injuries during laparoscopic cholecystectomy can achieve the best results and minimize postoperative period. The repair aims to restore bile flow through the biliary system and the prevention of short and long term complications such as biliary fistula, peritoneal abscess, intra-abdominal abscess, recurrent cholangitis and secondary liver cirrhosis.