Iatrogenic bile duct injuries remain a persistent risk and pose a challenging problem to repair. This chapter provides an introduction to management of these injuries with two basic repair techniques: Primary repair and biliary reconstruction with Roux-en-Y hepaticojejunostomy. Regardless of the type of repair, data suggests that repair of a bile duct injury has a better outcome (better patency rate and fewer complications) if done by a hepatobiliary surgeon. When a biliary injury is suspected or detected intraoperatively, obtain consultation with an experienced biliary surgeon.

Whether calling a colleague into the operating room or making a phone call to the local referral center, it is important to step back once the injury is discovered and seek assistance. The immediate goal is to prevent further damage to the duct or other portal structures and to control bile leakage until the definitive repair can be performed.

Biliary injuries may not become apparent until the postoperative period. In these cases, the same principles of expert consultation, limiting infection, and preventing further injury apply.

The timing of the repair can be immediate or delayed. Immediate repair should only be undertaken within 3 to 4 days after injury and if there is no evidence of sepsis and the biliary anatomy can be defined preoperatively. Otherwise appropriate biliary drainage and/or decompression should be obtained percutaneously and the repair undertaken 6 weeks later. Primary repair of noncircumferential bile duct injuries should only be done as an immediate repair.

Before undertaking operative repair, it is important to control sepsis. In patients presenting with abdominal pain, fever, and/or leukocytosis, an ultrasound or CT scan of the abdomen and pelvis should be performed to evaluate for fluid collections. Drain any identified collections. Treat patient with signs of sepsis with broad spectrum antibiotics. Dilated intrahepatic bile ducts often indicate downstream obstruction; have these
decompressed by a percutaneous transhepatic cholangiocatheter (PTC) as they pose a significant risk of cholangitis. Biliary catheters are often helpful intraoperatively in locating the bile duct and PTC’s can also be used postoperatively to stent the biliary anastomosis. Correct fluid deficits and electrolyte imbalances should be corrected and nutrition should be optimized.

Before undertaking repair of a common bile duct injury, it is imperative to define the ductal anatomy and type of injury as well as ensure patency of the hepatic arterial supply. This can be done with endoscopic retrograde cholangiopancreatography (ERCP), PTC cholangiography, or magnetic resonance cholangiopancreatography (MRCP). In patients with a drain in place undergoing delayed repair, a fistulogram through the drain can be performed after 2 to 3 weeks as an alternative method to define the ductal anatomy. The hepatic arteries can usually be adequately evaluated with duplex ultrasound or contrasted axial imaging. Inadvertent ligation of the hepatic artery or its major branches may affect the blood supply to the planned anastomosis or to large areas of the biliary tree.

Multiple biliary injury classification systems have been described. Such classification systems help standardize the definition of anatomic injuries and facilitate effective communication regarding the injuries between healthcare providers. The original Bismuth classification, listed in Table 76.1, has been expanded to include additional injuries encountered after laparoscopic cholecystectomy. The expanded Bismuth classification is commonly used to define the various sites of possible injury (Fig. 76.1). The original Bismuth classification corresponds to the E₁ through E₅ in the figure. In type 1 and type 2 injuries, the injury or stricture is on the common hepatic duct with a hepatic duct stump greater than 2 cm in length in type 1 and less than 2 cm in length in type 2 (Fig. 76.2). In type 3 injury, the confluence of the hepatic duct is intact but there is no remaining duct below the confluence. In type 4 injury, the left and right hepatic ducts are separated by injury at the confluence (Fig. 76.3). In type 5, there is injury to an aberrant right segmental branch with or without involvement of the common hepatic duct (Fig. 76.4).