Cholecystectomy Iatrogenic Bile

Duct Injury
April 28, 2005
OHSU, Department of Diagnostic Radiology
Kan Hwee, MS4

Content
I.
II.
III.
IV.

History and Overview of Bile Duct Injury

Biliary Anatomy Review
Bile Duct Images
Overview Management of Bile Duct
Injury

History and Overview

of Bile Duct Injury

History
Open cholecystectomy standard practice until late
1980s when laparoscopic cholecystectomy
became more common
Currently approx. 500,000 cholecystectomy
performed per year in the U.S.
Laparoscopic cholecystectomy
General advantages
Reduced post-op recovery, shorter hosp stay
Reduced pain, less surgical trauma
Improved cosmesis

However, reported increase in serious bile duct

complications and injuries
LeBlanc, Karl et al. Management of Laparoscopic Surgical Complications, 1st ed., Marcel Dekker, 2004.

Bile Duct Injury

Common etiology of injury
Poor visualization
Difficult or variant anatomy
Improper technique

Common mechanism of injury

Misidentification: excision, incision, or laceration of
common bile duct (CBD) or hepatic ducts resulting in
bile obstruction, bile leak
Electrocautery, thermal injury: stricture of CBD or
hepatic ducts, bile leak
Mechanical trauma: stricture of CBD or hepatic ducts,
bile leak

Bile Duct Injury, Cont

Post-op clinical signs
Persistent abdominal pain out of proportion to post-op pain, ileus,
anorexia, could develop chemical then bacterial peritonitis,
guarding, rigidity, fever, nausea, vomiting
Bile leak typically presents 3 -12 days post-op

Could present with pulmonary symptoms similar to pulmonary

embolism from bile irritation of diaphragm
Chest and shoulder pain
Shortness of breath, tachypnea, tachycardia

Depending on the severity of injury, presentation could occur days

to months after initial surgery

Reported incidence of bile duct injuries

Open cholecystectomy: 0.1% to 0.5%
Laparoscopic cholecystectomy: 0.3% to 1.2%
Wudel, James et al., Am Surg, June 2001.
Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

Bismuth Classification

Type I, involves the common duct with a normal hepatic stump of 2

cm or greater
Type II, involves the common duct with normal hepatic stump of less
than 2 cm
Type III, high injury with preserved ductal confluence
Type IV, destruction of the confluence
Type V, right sectoral duct with or without common bile duct injury

Left
Hepatic
Duct
Right
Hepatic
Duct

Common
Hepatic
Duct

Khalid, Tahir et al., Am J of Roent, December 2001; 177:1347-1352.

Biliary Anatomy Review

Biliary Anatomy

Biliary Anatomy, Cont.

a. Right hepatic duct.
b. Left hepatic duct.
c. Common hepatic duct.
d. Portal vein.
e. Hepatic artery.
f. Gastroduodenal artery.
g. Right gastroepiploic artery.
h. Common bile duct.
i. Fundus of the gallbladder.
j. Body of the gallbladder.
k. Infundibulum.
l. Cystic duct.
m. Cystic artery.
n. Superior pancreaticoduodenal
artery.

Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Normal Hepatic Biliary Anatomy

Normal hepatic biliary segmental anatomy, as described by Couinaud, and normal

fusion of cystic duct with common hepatic duct. Normal confluence of right posterior
duct (small arrowheads) and right anterior duct (large arrowheads) to form right
hepatic duct (arrow).
Mortele, Koenradd et al., Am J of Roent, August 2001.

Cystic Duct Variations

Common variants: A. Low cystic duct insertion, (10%); B. Parallel at least 2-cm with
common hepatic duct (15-25%); F,G,H. Medial cystic duct insertion (10-17%).
Uncommon variants: C. High fusion with hepatic duct; D. Fusion at right hepatic duct;
F. No cystic duct.
Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
Mortele, Koenradd et al., Am J of Roent, August 2001.

Bile Duct Images

Normal Biliary Tree

Normal hepatic ductal anatomy in 27-year-old healthy female volunteer. MRC

showing normal fusion of draining duct of segment I (arrowhead) with left hepatic
duct. Note normal confluence (small arrow) of right posterior duct and right anterior
duct. Cystic duct (large arrow).
Mortele, Koenradd et al., Am J of Roent, August 2001.

Common Biliary Variant

Common biliary variant in 45-year-old woman with

cholelithiasis. MRC showing medial and low insertion
of the cystic duct (arrow).
Mortele, Koenradd et al., Am J of Roent, August 2001.

Common Biliary Variant

Common biliary variant in 33-year-old woman with cholestasis. MRC showing

> 2 cm parallel course of cystic duct and common hepatic duct (arrows). In
addition, note drainage of right posterior duct (arrowhead ) into left hepatic
duct.
Mortele, Koenradd et al., Am J of Roent, August 2001.

Common Biliary Variant

Common biliary variant in 34-year-old woman with recurrent cholestasis after

cholecystectomy. MRC showing triple confluence of right anterior duct (small
arrowhead), right posterior duct (small arrow), and left hepatic duct (large
arrowhead). Cystic stump (large arrow).

Mortele, Koenradd et al., Am J of Roent, August 2001.

Uncommon Biliary Variant

Uncommon biliary variant in 62-year-old woman after

cholecystectomy. MRC showing high insertion of cystic duct (arrow)
into common hepatic duct (arrowhead).

Mortele, Koenradd et al., Am J of Roent, August 2001.

Uncommon Biliary Variant

Uncommon biliary variant in 54-year-old man with chronic pancreatitis. MRC

showing aberrant drainage of right posterior duct (arrow) into common hepatic duct
(small arrowhead). Note pancreas divisum with ductal changes involving dorsal
dominant duct (large arrowheads).

Mortele, Koenradd et al., Am J of Roent, August 2001.

Bile Leak

CT scan of patient with bile leak after

cholecystectomy. The short arrows indicate
the intraperitoneal collections. Both air and
bile is seen in the gallbladder bed (long
arrow) as is a surgical clip.

An ERC of same patient showing a leak

from the cystic duct stump (arrow). Note the
filling of the pancreatic duct.

Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Bile Duct Stricture

Bile duct stricture at cystic duct origin in 17-year-old boy who presented with
obstructive jaundice 1 month after laparoscopic cholecystectomy that was converted to
open cholecystectomy because of difficulty in extracting impacted cystic duct calculus.

MRCP showing moderate intrahepatic and extrahepatic

biliary dilatation caused by short tight stricture (arrow) of
common bile duct where cystic duct origin once began.
Intact distal bile duct segment is seen below stricture.

Khalid, Tahir et al., Am J of Roent, December 2001; 177:1347-1352.

PTC showing stricture (arrow) that was

subsequently balloon-dilated.

Excisional Injury
Excision injury with ligation in 35-y/o woman who presented 1 week
after laparoscopic cholecystectomy with right upper quadrant pain and
jaundice.

MRCP showing moderate intrahepatic biliary dilatation

and cutoff approx. 1 cm distal to bifurcation caused by
ligation injury. Segment of extrahepatic bile duct 1.8
cm long is missing (arrows).
Khalid, Tahir et al., Am J of Roent, December 2001; 177:1347-1352.

ERCP image showing distal one third of bile duct with

abrupt cutoff (arrow) and multiple surgical clips in
subhepatic area.

Cystic Duct Leak

MRCP showing fluid collection (curved arrows)

adjacent to cystic duct remnant (straight arrow).

Khalid, Tahir et al., Am J of Roent, December 2001; 177:1347-1352.

ERCP image confirming subhepatic bile leak (arrow).

Cystic Duct Leak

69-y/o woman with abdominal pain, nausea, and vomiting after undergoing
laparoscopic cholecystectomy.

Axial gradient-echo MR cholangiogram obtained 1

hr after IV administration of mangafodipir trisodium
shows extravasation of contrast material (arrows)
into perihepatic space.
Vitellas, Kenneth et al., Am J of Roent, August 2002.

Axial gradient-echo MR image shows

extravasation of contrast material (straight arrows)
and site of leak at base of right hepatic duct
(curved arrow). Opacified common bile duct
(arrowhead) indicates continuity with liver,
confirmed on ERCP.

Cystic Duct Leak

75-y/o woman with bile leak from cystic duct remnant 1 week after
laparoscopic cholecystectomy.

Coronal fat-suppressed T2-weighted image

shows small collection adjacent to cystic duct
remnant (arrow). Patient was treated with
percutaneous drainage.
Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

Coronal volumetric maximum-intensity-projection

mangafodipir trisodiumenhanced image confirms
extravasation of contrast material into subhepatic
space (arrow).

Right Aberrant Duct Excision

56-y/o man with mild abdominal discomfort for 21 days after laparoscopic cholecystectomy.

Coronal MRCP obtained

before mangafodipir
trisodium (MnDPDP)
enhancement with thickslice half-Fourier RARE
sequence showing mildly
dilated and disconnected
right posterior duct
(arrow).

Max-intensity image from

ERCP image with right
coronal 3D volumetric
posterior duct not
interpolated T1-weighted
seen.
gradient-echo image obtained
30 min after injection of
MnDPDP showing
opacification of right posterior
duct (arrow) suggesting
possible partial ligation of
aberrant right posterior duct.

Park, Mi-Suk et al., Am J of Roent, December 2004.

Hepatobiliary scintigram
obtained 90 min after
injection of iminodiacetic
acid, 2 months after
MRCP, shows photondefect area (arrows) in
right lobe of liver.

Stricture with Cystic Duct Leak

35-y/o man with abdominal pain and fever for 10 days after laparoscopic cholecystectomy.

Coronal MRC obtained before

mangafodipir trisodium
(MnDPDP) enhancement with
thin-section half-Fourier RARE
sequence shows narrowing of
common bile duct (thin arrow)
with abnormal fluid collection
(thick arrow).

Coronal 3D volumetric interpolated

T1-weighted gradient-echo image
obtained 30 min after injection of
MnDPDP showing enhanced
extrahepatic duct, in spite of a
narrowing segment (thin arrow),
with extravasation of contrast agent
(thick arrow).

Park, Mi-Suk et al., Am J of Roent, December 2004.

ERCP image showing partial

stricture (thin arrow) of
common bile duct with bile
leakage (thick arrow).

Bismuth I Injury
39-y/o man with Bismuth type I injury 1 week after laparoscopic cholecystectomy.

MRC showing stricture (arrow) at level of common hepatic duct more

than 2 cm from biliary confluence. Patient was treated with hepaticojejunostomy.

Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

Bismuth III Injury

41-year-old woman with Bismuth type III injury 8 days after laparoscopic cholecystectomy .

MRC showing stricture (arrow) at level of common hepatic duct, leaving

biliary confluence intact. Patient was treated with hepaticojejunostomy.

Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

Bismuth IV Injury
63-y/o man with Bismuth type IV injury 10 days after laparoscopic cholecystectomy.

MRC showing stricture at level of common

hepatic duct with extension and partial destruction
of biliary confluence (arrows). Patient was treated
with hepaticojejunostomy.
Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

MRC maximum-intensity-projection image showing

similar stricture at level of common hepatic duct with
extension and partial destruction of biliary
confluence (arrows).

Bismuth V Injury
54-year-old woman with Bismuth type V injury 12 days after laparoscopic cholecystectomy.

MRC showing stricture at level of right

posterolateral duct (short arrow) with associated
involvement of common hepatic duct (long arrow).
Patient was treated with hepaticojejunostomy.
Ragozzino, Alfonso et al.. Am J of Roent, December 2004.

T-tube cholangiogram showing only distal part

of biliary tree with no visualization of common
hepatic duct or intrahepatic biliary tracts.

Overview Management of Bile

Duct Injury

Management of Bile Duct Injuries

About 25% of injuries recognized intraoperatively
About 50% of injuries discovered within 24 hours
post-op
About 50% of injuries present weeks to years
post-op
Common complications of bile duct injuries
Bile leak, subhepatic or subphrenic abscess, hemobilia,
external biliary fistula, cholangitis
Long-term secondary cirrhosis, portal hypertension

Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

Management of Bile Duct Injuries, Cont.

Acute Management
Biliary catheter for decompression of biliary tract and
control of bile leaks
Percutaneous drainage of intraperitoneal bile collection

Corrective Treatment
Balloon dilation for minor strictures or endoscopic stenting
for strictures
T-tube placement for minor lacerations
Primary duct-to-duct repair only if tension free anastomosis
available
Biliary anastomosis with jejunal loop for major excisional
injuries
Schwartzs Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.
Wudel, James et al., Am Surg, June 2001.

Bibliography
1.
2.
3.

Schawartzs Principles of Surgery, 8th ed., The McGraw-Hill Companies, 2005.

LeBlanc, Karl et al. Management of Laparoscopic Surgical Complications, 1 st ed., Marcel Dekker, 2004.
Lanzafame, Raymond, et al. Prevention and Management of Complications in Minimally Invasive
Surgery, Igaku-Shoin Ltd., 1996.
4. Sawaya, David et al. Iatrogenic and Noniatrogenic Extrahepatic Biliary Tract Injuries: A MultiInstitutional Review, The Am Surg, May 2001, 67:473-477.
5. Wudel, James et al. Bile Duct Injury Following Laparoscopic Surgery: A Cause for Continued Concern,
The Am Surg, June 2001, 67:557-565.
6. Mortele, Koenradd et al. Anatomic Variants of the Biliary Tree: MP Cholangiographic Findings and
Clinical Applications, Am J of Roent, August 2001; 177:389-394.
7. Ragozzino, Alfonso et al. Value of MR Cholangiography in Patients with Iatrogenic Bile Duct Injury
After Cholecystectomy. Am J of Roent, December 2004; 183:1567-1572.
8. Khalid, Tahir et al. Using MR Cholangiopancreatography to Evaluate Iatrogenic Bile Duct Injury, Am J
of Roent, December 2001; 177:1347-1352.
9. Park, Mi-Suk et al. Early Biliary Complications of Laparoscopic Cholecystectomy: Evaluation on T2Weighted MR Cholangiography in Conjunction with Mangafodipir Trisodium-Enhanced 3D T1Weighted MR Cholangiography, Am J of Roent, December 2004; 183:1559-1566.
10. Vitellas, Kenneth et al. Using Contrast-Enhanced MR Cholangiography with IV Mangafodipir
Trisodium (Teslascan) to Evaluate Bile Duct Leaks After Cholecystectomy: A Prospective Study of 11
Patients, Am J of Roent, August 2002; 179:409-416.