International Journal of Scientific & Engineering Research, Volume 5, Issue 7, July-2014 583

ISSN 2229-5518

Study of bile duct injuries in tertiary care centre during cholecystectomy

Dr Jitendra Sankpal, Dr Spoorthy Shetty, Dr Manjiri Sankpal, Dr Vivek Tilwani, Dr Vijay Nikale, Dr Ashish Hatkar

Abstract— currently, about 90% of cholecystectomies are performed using the laparoscopic approach. Despite the rapid incorporation of laparoscopic cholecystectomy into current surgical practice, open cholecystectomy remains an extremely safe procedure with low morbidity and mortality.Despite the extensive experience with laparoscopic surgery, the incidence of intra-operative injury with open cholecystectomy remains about half the incidence of laparoscopic cholecystectomy. There are several reasons that the bile duct is at increased risk of injury during laparoscopic cholecystectomy compared with open cholecystectomy. It has long been argued that surgeon inexperience is a major culprit, and that with increased familiarity with the procedure, the number of injuries will decrease: the so-called 'learning curve effect'. Several authors have shown an inverse relationship between the incidence of bile duct injuries and number of cases performed. Also, large population-based reviews have documented a decline in injuries over time and some authors have noted a decline in the number of injuries referred for repair. These trends, while encouraging, have not been observed by all investigators, however. Several contemporary reports have suggested no change in the incidence of bile duct injuries over time and the number and complexity of cases referred for repair has remained static at some specialist units.Moreover, reports of major bile duct injuries inflicted by surgeons with considerable experience continue to appear. The data would therefore suggest that postcholecystectomy bile duct injuries will remain a significant problem for the forseeable future. A total of 1250 cholecystectomies were carried out and incidence of Bile duct injury was 2.4%.Majority of the bile duct injuries were seen in patients undergoing cholecystectomy for cholecystitis of > 72 hours duration. Among the 30 cases of BDI 50% were done laparoscopically and 23% were open cholecystectomies. Of the 20 cases done laparoscopically 27% were converted to open. BDI

was recognized intraoperatively in 30%, in the early postoperative period (<1 wk) in 50% and only 06 case was identified in the late postoperative period. Intraoperative cholangiogram was done to define bile leakage in 9 cases only.The site of BDI was determined to be CHD in 27.6%, CBD in 48.3%, cystic duct in 20.7% and from the gall bladder bed in 3.4% of the cases.31% of the BDI were of Strasberg type A, the most common type of injury in present Study.In present study most common modality of treatment used is Hepatico- jejunostomy and ERCP with Stenting. Intra-operatively diagnosed patients required primary suturing over T-tube in most cases.

Index Terms— Open cholecystectomy, Bile duct injuries(BDI), laproscopic cholecystectomy(LC), common bile duct(CHD), Common hepatic duct(CHD)


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he biliary tract is a complex organ system that performs the simple though vital task of collecting, storing, and de- livering bile to the gastrointestinal tract. Diseases of the biliary tract can be extremely painful, debilitating, and occa- sionally life threatening. The complex development of the liver and biliary system in utero can result in multiple anatomic variations. An absolute knowledge of these anatomic varia- tions with careful dissection and identification of structures at the time of surgery is a minimal requirement for the safe per- formance of any hepatobiliary operation. Because of the un- forgiving nature of the biliary system, errors in technique or judgement can be disastrous to the patient, resulting in life- long disability or death. For this reason, a high premium exists on performing the correct procedure, without technical mis- adventure, the first time. Equally important is the ability to recognize iatrogenic injury so that prompt repair or Referral to a surgeon who has expertise in hepatobiliary surgery can be instituted. Positive outcome requires a balance between sound judgement, technical acumen, and attention to detail. Addi- tionally, the surgeon of today must be able to integrate surgi- cal options with the broadening array of radiologic and endo- scopic treatment options available in the management of pa- tients who have these disorders.Also because of the great fre-
quency with which the operation is performed, cholecystectomy remains the greatest source of post-operative biliary injuries.In a review of more than 42,000 open cholecys- tectomies performed in the United states in 1989, the incidence of incidence of biliary injuries was documented to be 0.2%(1). Strasberg and associates reported a 0.3% incidence of injuries in aliterature review of of more than 25,000 open cholecystec- tomies since 1980(2). The advent and preference for laparo- scopic cholecystectomy has refocused attention on this issue, however because of the significant increase in the number of Injuries. Several studies worldwide have documented a marked increase in the frequency of bile duct injuries associat- ed with the laparoscopic approach, ranging from 0.4% to 1.3
%( 3, 4, 5, 6, and 7). Also in a review of nearly 125,000 laparo- scopic Cholecystectomies reported in the literature in the years
1991-1993, Strasberg and colleagues reported an overall inci- dence of of biliary injuries of 0.85%.Aim of present study was to analyse incidence of bile duct injuries in tertiary care centre after cholecystectomy.
The objective of the current study is-

1. To analyse surgical incidence of bile duct injuries.

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2. To identify and analyse risk factors (pre op and intra op) responsible for bile duct injuries.

3. To study nature, size, extent of bile duct injuries with respect to standard classification (Bismuth’s, Strass- berg’s classification).

4. To study associated injury in addition to bile duct in- jury.

5. To study the various intra-op modalities of treatment employed for immediately recognized bile duct inju- ries.

6. To study the various post-op modalities of manage- ment employed for post operatively recognized bile duct injuries (<7days).

7. To study the various intra-op modalities of manage- ment employed for delayed recognized bile duct inju- ries.

8. To study various modalities of presenting treatment employed for bile duct strictures as a consequences of bile duct injuries.

9. To study the complications arising out of intra opera-

tive, delayed (1-7 day) and late (7-21days) of bile duct

10. To study the mortality and morbidity associated with

bile duct injuries
The present study includes patients with bile duct injuries following cholecystectomy admitted in tertiary care centre from 2011 to 2013.


1. Patient’s >12 years of age group.
2. Patient’s willing for study.
3. All patient’s with bile duct injuries.
4. Blunt abdominal trauma.


1. Patient’s< 12 years of age group.
2. Patients not willing to participate in study group.
3. Pregnant women.


A total of 1250 cholecystectomies were carried out in the study period. The incidence Of Bile duct injury was 2.4 %( 30 patients). The mean age was 41.03yrs with a standard devia- tionof 10.9 and a range of 30-50 yrs.70% of the patients were female. 21 patients (70%) underwent cholecystectomy 72 hours after onset of symptoms and 9 patients (30%) within 72 hours of onset of symptoms. Patient distribution with type of chole- cystectomy is shown in table 1.Majority of the bile duct inju- ries were seen in patients undergoing cholecystectomy for cholecystitis of > 72 hours duration. Among the 30 cases of BDI 50% were done laparoscopically and 23% were open chol- ecystectomies. Of the 20 cases done laparoscopically 27% were converted to open. (TABLE 1)
Among the 30 cases of BDI, 9 were cases of documented BDI referred to our hospital for further management. BDI was rec- ognized intraoperatively in 30%, in the early postoperative period(<1 wk) in 50% and only 06 case was identified in the late postoperative period.(table 2). Intraoperative cholangio-
gram was done to define bile leakage in 9 cases only.
In the patients with BDI, one (30%) had cholangitis, another
(4%) had pancreatitis and two patients (8%) had choledocho-
lithiasis. Three of the patients (12%) with BDI had cholecystitis
of <72 hours duration. 28% of bile duct injuries were noted in
patients with the above risk factors. Majority of the patients
who did not undergo any definitive surgery for the bile duct injury immediately in the same setting were evaluated post- operatively with an ultrasound abdomen and pelvis (60%), further evaluation to detect the site of injury was done with a
CT abdomen (17%), ERCP (64%) and PTBD (12%).
31% of the BDI were of Strasberg type A, the most common type of injury in ourstudy. 20.7% were Strasberg E1, 24.1% each of Strasberg D and E2, 20.7% of Strasberg E3 type(TABLE
2). Nine of the thirty cases of BDI were identified intraopera- tively. Four were sutured with absorbable materials in an in- terrupted fashion with t-tube; two of these underwent in- traoperative cholangiogram to define the site of injury. One case required the cystic duct stump to be clipped additionally; one of the lower CBD injuries required a choledochoduode- nostomy, in another case T-tube drainage was later followed up by hepaticojejunostomy. Two of the cases required postop- erative ERCP with stenting of the lower CBD and percutane- ous drainage.
Fifteen cases of BDI were identified within a week of undergo- ing cholecystectomy.Five of these underwent hepaticojejunos- tomy,one required A choledochoduodenostomy, three were managed with percutaneous drainage postoperatively, two cases were managed with end to end ductal closure with a stent in place. Six cases of BDI was recognized in the late post- operative period and was managed with a hepaticojejunosto- my.The site of BDI was determined to be CHD in 27.6%, CBD in 48.3%, cystic duct in 20.7% and from the gall bladder bed in
3.4% of the cases.
In present study most common modality of treatment used is Hepatico-jejunostomy and ERCP with Stenting. Most of the intra-op diagnosed patients required primary suturing over T- tube. Other patients required Percuteneous drainage; Usg guided drain, Clipping of cystic duct for stump blow out. For Intra-op diagnosed patients four were managed with pri- mary suturing with T-tube, in two we kept stents, one patient required Choledocho-jejunostomy and in one patient we ap- plied clip . In immediately post operatively diagnosed bile duct injuries most commonly used modality is ERCP with Stenting.Those patients who were diagnosed late (7-21days) were managed with Hepatico-jejunostomy. (FIGURE 1)
In September 1985, Erich Muhe20 performed the first LC. Although at the time the surgical community was skeptical of his new operation, by the early 1990s, “minimally invasive surgery,” including LC, was prevalent in clinical practice Surgeons around the world were beginning to perform the operation, report case series, and implement guidelines for the procedure. The widespread acceptance and application of LC brought not only the obvious benefits of decreased postopera- tive pain and length of hospital stay but was associated with a

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troublesome increase in certain complications and, specifical- ly, BDI. Over the last decade, BDI following LC has become recognized as a major health problem, as evidenced by studies evaluating the postoperative management and long-term quality-of-life outcomes of patients.
Despite expectations that the rate of BDI would decrease over time as the “learning curve” of LC flattened, the rates appear to have reached a plateau, as evidenced by a recent review of nearly 1.6 million cholecystectomies performed among Medicare beneficiaries. These studies revealed a steady
0.5% incidence of BDI from 1992 to1999. Unfortunately, BDI appears to be a complication that may continue to exist at Rates greater than in the pre-LC era.Despite improvements in technology, BDI continues to pose a significant clinical chal- lenge. Proper diagnosis and appropriate treatment of BDI are paramount in preventing life-threatening complications of Cholangitis, biliary cirrhosis, portal hypertension, end-stage liver disease, and death.
Although the mechanisms of bile duct injury during lapa- roscopic cholecystectomy are varied, the common denomina- tor is failure to recognize the anatomy of the triangle of Calot. This failure can be attributed to anatomic risk factors, factors inherent in the laparoscopic technique, or inadequate training. Anatomic risk factors may include acute or severe chronic in- flammation, morbid obesity, bleeding, and the presence of Anatomic anomalies. Factors inherent in the laparoscopic technique include the lack of depth perception, differences in the lines of traction of the gallbladder, the difficulty of per- forming antegrade cholecystectomy, and the use of the elec- trocautery or laser in a limited field that can be easily obscured by blood or bile.
The current study illustrates the magnitude of the problem resulting from BDI. Most of the injuries were noted in the fourth and fifth decades of life with a slight female prepon- derance. The rate of BDI in our study is higher being 2.31% when compared to other studies where the rate of BDI after laparoscopic cholecystectomy was noted between 0.4% to 0.6
%( 8, 9, 10, and 11). This could be attributable to the learning curve for laparoscopic surgery in our institution. 30% of the BDI were noted in patients undergoing cholecystectomy for cholecystitis of <72 hours duration. This underlies the difficul- ties in performing a safe surgery in situations where the anat- omy of the Calot’s triangle is unclear. No aberrant vascular or ductal anatomy was encountered in this study.Fifty percent of the injuries occurred during laparoscopic cholecystectomy. Thirty percent of these were converted to open procedure.
While less than a third of the bile duct injuries are recog- nized intraoperatively. In our study this rate was 30% Majori- ty of these were managed at the same time immediately after recognition during cholecystectomy. Multidisciplinary ap- proach involving surgeons, hepatobiliary surgeon and inter- ventional radiologists in management of complications is es- sential. The most frequent investigation used to determine BDI postoperatively was ultrasound of the abdomen and pelvis. ERCP, PTC, PTBD were used to further delineate the bile duct anatomy and site of injury.
In our study the most common site of BDI was found to be the common hepatic duct. Strasberg type A was the most
common BDI encounterd in our study. This is in agreement with the findings in another study by Strasberg et al. Most of the cases of BDI were managed by a definitive repair; these were assisted with radiological interventions in the form of ERCP and stenting, PTBD. A minority were managed by stent- ing only and did not require any surgical intervention. Most of the BDI recognized intraoperatively belonged to Strasberg
type A and 54% of these were managed with primary suturing or additional clipping of the cystic duct leak. For the injuries discovered postoperatively the most common surgery done was the Roux-en-Y hepaticojejunostomy. Of the thirty BDI profiled, five were referred from other hospitals/surgeons for further management. Most of these cases were managed
With a Roux-en-Y hepaticojejunostomy while one patient ex- pired.
There are several factors associated with an increased risk of bile duct injury at cholecystectomy, some of which are general and some unique to the laparoscopic approach .Ultimately, however, the final common pathway of most injuries is either atechnical error or misinterpretation of the anatomy.Thus it is essential for young budding surgeons to be aware of the all
the above factors and abberant anatomy to perform safe chole- cystectomy. Finally, failure to perform laproscopically does
not mean complete failure of surgery. A good surgeon must always be willing to convert to open cholecystectomy when in doubt.

Table 1: Shows method for cholecystectomy chosen in study group




Laproscopic cholecystectomy



Laproscopic converted open chole- cystectomy



Open cholecystectomy



Tabe 2: site of bie duct injuries

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and survival in Medicare beneficiaries. JAMA 2003;290(16):2168-73.

9. Ooi LL, Goh YC, Chew SP, et al. Bile duct injuries during laparoscopic cholecystectomy:a collective experience of four teaching hospitals and results of repair. Aust N Z J Surg 1999;69(12):844-6.

10. Waage A, Nilsson M. Iatrogenic bile duct injury: a population based study of

152 776 cholecystectomies in the Swedish Inpatient Registry. Arch Surg


11. Sicklick JK, Camp MS, Lillemoe KD, et al: Surgical management of bile duct injuries sustained during laparoscopic cholecysyectomy: perioperative results

in 200 patients. Ann Surg 2005:241(5):786-792.

Fig 1: Treatment modality in study group


Bile duct injury remains a dreaded complication in all cases of cholecystectomy. The incidence would naturally be higher in teaching institutes.Incidence of BDI at our institution is higher in comparision to similar studies. Factors such as acute chole- cystitis, cholangitis, pancreatitis, and choledocholithiasis are Contributory to occurrence of BDI and help of senior col- leagues should be sought in cases with such co- morbidities.Detailed investigations to determine the site of injury is a must prior to any definitive repair.


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3. Adamsen S, et al, 1997: Bile duct injury during laparoscopic cholecystectomy:

a prospective nationwide series. . J Am Coll Surg 184:571-578.

4. Deziel DJ,et al, 1993: Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. J Am Coll Surg 165:9-14.

5. MacFadyen JB, et al, 1998: Bile duct injury after laparoscopic cholecystectomy: the United States experience. Surg Endosc 12:315-321.

6. Richardson MC,et al, 1996: Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group. Br J Surg 83:1356-1360.

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