Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. This video shows the laparoscopic management of biliary peritonitis after complete division of a posterior right lateral branch.
The incidence of accessory hepatic ducts is reported to range from 1.4% to 27% and has been found to range from 15% to 28% in autopsy series (1,2,3).
Injury of the extra-hepatic bile ducts (BDI) is the most serious complication when performing cholecystectomy, leading to biliary leakage and peritonitis. Treatment and prevention of this complication are essential in the management of gallstone diseases. The incidence of this complication depends on local inflammation at the hepatoduodenal ligament, on the type of approach used, and on the experience of the surgeon (4,5).
Injuries of tiny posterior aberrant ducts, which enter the main duct proximal to or within the cystic duct, may accidentally occur during surgery, causing partial or total segmental duct obstruction or bile leakage. Bile duct injuries can be split into five groups according to the mechanism of etiology or to the severity of the lesion.
The most commonly used classification of acute bile duct injuries (BDI) is the one proposed by Strasberg et al. (6):
Type A: bile leak from a minor duct still in contact with the common bile duct;
Type B: occlusion of part of the biliary tree;
Type C: bile leak from the duct not in contact with the common bile duct;
Type D: lateral injury to extra-hepatic bile duct;
Type E: circumferential injury of major bile ducts.
Here, the clinical case presents a type C lesion successfully managed through a conservative surgical approach.
1. Seibert D, Matulis SR, Griswold F. A rare right hepatic duct anatomical variant discovered after laparoscopic bile duct transection. Surg Laparosc Endosc 1996;6:61-4.
2. Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. AJR Am J Roentgenol 1999;172:955-9.
3. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K. Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. AJR Am J Roentgenol 2000;175:713-20.
4. Hugh TB. New strategies to prevent laparoscopic bile duct injury--surgeons can learn from pilots. Surgery 2002;132:826-35.
5. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR. Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 1998;12:315-21.
6. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.