Saudi Surgical Journal

: 2019  |  Volume : 7  |  Issue : 3  |  Page : 95--99

Management of nonvascular postlaparoscopic bile duct injury

Bilal O Al-Jiffry1, Mohamed Al Saeed1, Majed Al-Mourgi1, Samir Badr2, Tamer Abdel-Rahman3, Abdel-Hafez Shweel4, Alaa E Younes1, Abdullah Al-Sawat1, Aseel Abu-Duruk1, Owaid Al-Malki1, Mohamed Hatem5, Mahmoud El-Meteini6,  
1 Department of Surgery, Taif University, Taif, Saudi Arabia
2 Department of Surgery, Taif University, Taif, Saudi Arabia; Department of Surgery, General Organization of Teaching Hospitals and Institutes, Damanhur, Benha, Egypt
3 Department of Surgery, Taif University, Taif, Saudi Arabia; Department of Surgery, General Organization of Teaching Hospitals and Institutes, Benha, Egypt
4 Department of Surgery, Zagazig University Hospitals, Zagazig, Egypt
5 Department of Surgery, Taif University, Taif, Saudi Arabia; Ain Shams Organ Transplant Center, HBP and Liver Transplant Unit, Cairo, Egypt
6 Department of Hepatobiliary Surgery, Ain Shams Center for Organ Transplant, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Correspondence Address:
Abdullah Al-Sawat
Department of Surgery, Taif University, Taif
Saudi Arabia


Background and Aim of the Work: Early management of postlaparoscopic nonvascular biliary injuries by an expert team is essential to achieve a good outcome. In this article, we would evaluate the results of this prospective multicentric study in the management of postlaparoscopic nonvascular biliary injuries. Patients and Methods: This prospective multicentric study enrolled 168 patients with iatrogenic nonvascular bile duct injury (BDI). In all cases, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and further management was done according to Strasberg type of injury. Results: Intra-abdominal biliary collection was managed by ultrasound-guided drainage. Type A (19%) was diagnosed and treated by ERCP. Types B and C (20.2%) were treated by duct reconstruction of the isolated segment and Roux-en-Y hepaticojejunostomy (RYHJ), respectively. Strasberg type D nondevascularized partial injury (7.1%) was treated by primary repair around stent. In complete type D patients and E (10.7% and 43%, respectively), Roux en-Y hepaticojejunostomy with lowering the hilar plate was performed. After ERCP, 78% of patients developed hyperamylasemia and only 4.8% developed pancreatitis. After HJ, 9.7% of patients developed stricture and were treated by percutaneous transhepatic cholangial dilatation. Conclusion: This study proved the safety and efficacy of the management of iatrogenic BDI by an expert team implementing different diagnostic and treatment modalities such as ultrasound, computed tomography scan, and ERCP in addition to different surgical options, particularly the use of right end-to-side and left side-to-side RYHJ, with lowering the hilar plate and anterior anastomosis.

How to cite this article:
Al-Jiffry BO, Al Saeed M, Al-Mourgi M, Badr S, Abdel-Rahman T, Shweel AH, Younes AE, Al-Sawat A, Abu-Duruk A, Al-Malki O, Hatem M, El-Meteini M. Management of nonvascular postlaparoscopic bile duct injury.Saudi Surg J 2019;7:95-99

How to cite this URL:
Al-Jiffry BO, Al Saeed M, Al-Mourgi M, Badr S, Abdel-Rahman T, Shweel AH, Younes AE, Al-Sawat A, Abu-Duruk A, Al-Malki O, Hatem M, El-Meteini M. Management of nonvascular postlaparoscopic bile duct injury. Saudi Surg J [serial online] 2019 [cited 2021 Jan 17 ];7:95-99
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Full Text


Laparoscopic cholecystectomy (LC) is considered the gold standard for the treatment of symptomatic gall stones; however, LC is associated with two- to four-fold increase in the risk of bile duct injury (BDI) more than the conventional cholecystectomy.[1],[2] In less than one-third of cases, BDI can be discovered intraoperatively, and the diagnosis is confirmed by cholangiography, mostly intraoperative cholangiography (IOC).[3] In the majority of cases, the BDI is discovered postoperatively where the patients usually present with nonspecific symptoms such as vague abdominal pain, nausea and vomiting, and a low-grade fever due to bile leak into the peritoneal cavity with formation of bile ascites and further delay usually leads to peritonitis, sepsis, cholangitis, or external biliary fistulae.[4] The patient may present later after the development of stricture with jaundice with or without cholangitis; furthermore, BDIs with vascular involvement may result in abscess formation, secondary biliary cirrhosis, or acute hepatic necrosis, and, in some situations, liver transplantation may be required.[5] In patients who present postoperatively with suspected BDI, the surgeon must not rush to surgery before delineating the biliary anatomy and the exact type and location of the injury.[2],[5],[6] The patient must be initially evaluated by ultrasonography and contrast-enhanced triphasic computed tomography (to detect vasculobiliary lesions).[7] Endoscopic retrograde cholangiopancreatography (ERCP) must be performed to delineate the biliary anatomy and confirm the presence and type of a biliary injury.[2],[8] ERCP has a definitive therapeutic value in minor biliary injuries and in complex injuries, it can facilitate the management by temporary internal stents.[8] Various classifications of BDIs were developed to facilitate treatment options, and most of the authors consider the Strasberg classification of BDI as the most complete and easy-to-understand classification. It divides BDI into five groups (A to E) where the E class is analogous to the Bismuth classification.[9],[10],[11] Only right and left partial injuries are not included in this classification; however, these types are not common, and the surgeon must be aware of them in order to make a proper diagnosis and timely referral to a more specialized center if needed.[9] The time of recognition of BDI is the cornerstone for proper management besides the extent and location of the injury.[11],[12],[13],[14],[15],[16],[17] If an expert multidisciplinary team of surgeons, interventional radiologists, and endoscopists are available, initial repair is the best opportunity for the best outcome; however, if an expert surgeon is unavailable, referral to a high-volume center for bile duct repair gives the patient the best chance.[2],[13],[17] In this article, we would evaluate the results of this prospective multicentric study in the management of postlaparoscopic nonvascular biliary injuries.

 Patients and Methods

This prospective multicentric study was conducted from May 2012 to May 2017 and enrolled 168 patients (120 females and 48 males) with a mean age of 44 ± 10.9 years. All patients presented postoperatively with biliary injury after LC and were managed by the teams of hepatobiliary surgery at our centers. The study was conducted after approval of the ethical boards in the hospitals and obtaining informed written consent from the patients. Out of the 168 cases, 126 cases (75%) were referred from other hospitals to our centers and in the other 42 patients, LCs were performed in our hospitals. Initial management included giving the patient a suitable antibiotic with fluid resuscitation if required which was followed by initial ultrasound assessment, and ultrasound-guided drainage (USGA) was applied if no or inefficient drain was found. Contrast-enhanced triphasic computed tomography (CT) scans were done to diagnose vascular injury, and all cases proved to have vasculobiliary injuries were excluded from the study. ERCP was performed in all cases, and further management was done according to Strasberg type of injury.[2] Type A injuries were treated endoscopically by sphincterotomy, removal of any retained stones, and stenting. Strasberg type B and C injuries required reconstruction of the isolated segment with Roux-en-Y-hepaticojejunostomy (RYHJ). Strasberg type D injuries were repaired primarily over an internal stent provided that there is no significant ischemia or cautery damage at the site of injury. Complete nondevascularized Strasberg type D and E injuries were treated by H-J to a Roux loop with lowering of the hilar plate and anterior anastomosis (right end to side and left side to side). A drain was removed in all the patients 5–7 days when there was no bile leak. The mean follow-up was 23 ± 5.6 months.

Statistical analysis

SPSS program, version 20.0 (SPSS Inc., Chicago, IL, USA), was used for statistical analysis. The qualitative data were expressed in number and percentage, whereas the quantitative data were expressed as means ± standard deviation.


Demographics, patient characteristics, and Strasberg types are shown in [Table 1]. The most common postoperative presentation was obstructive jaundice in 78/168 patients (46.4%), and there was associated cholangitis in 16/78 (20.5%) patients. There was a persistent bile leak from the drain in 64/168 patients (38.1%) and intra-abdominal biliary collection in 26 patients (15.5%), which were managed by USGA. Ultrasound and ERCP were performed in all patients, and contrast-enhanced triphasic CT was performed in 136/168 (81%) patients (diagnosed as types B–E). [Table 1] summarizes Strasberg types of the patients. [Table 2] shows the treatment modalities performed according to the Strasberg types. [Table 3] shows the complications and their treatment. RYHJ with lowering the hilar plate was performed in 124 patients (types B, C, complete D, and E patients). The mean follow-up period was 23 ± 5.6 months during which there was no recorded mortality. [Figure 1] shows common bile duct (CBD) resection at the bifurcation, with one catheter in the left hepatic duct and the other catheter in the right hepatic duct. [Figure 2] shows clips in the lower end of CBD and forceps on the upper edge of the common hepatic duct. [Figure 3] shows ERCP of post-LC, and the arrows reveal biliary leakage from the cystic duct stump due to slipped clips. [Figure 4] shows ERCP of post-LC, and the arrow reveals clipped CBD with complete arrest of the contrast.{Table 1}{Table 2}{Table 3}{Figure 1}{Figure 2}{Figure 3}{Figure 4}


Iatrogenic BDIs (IBDIs) remain an important problem in gastrointestinal surgery. Early and accurate diagnosis of IBDIs is very important for surgeons and gastroenterologists because unrecognized IBDIs lead to serious complications.[1],[2] Biliary injuries noted with LC can be simply minimized by following the basic rule to avoid ligation or division of any structure in the Callot's triangle until it is clearly identified.[1],[2],[6] There is an increase in the recorded BDI intraoperatively in the recent reports; however, previous studies showed that about one-third is detected only intraoperatively.[2],[9] Once these injuries are suspected, the surgeon should attempt to define their level before they worsen, with the aid of IOC.[2],[5],[9] Wu et al.[1] found that 71.1% of their patients were recognized in the early stage postoperatively, whereas 28.9% of patients presented late postoperatively. The time interval between the operation of cholecystectomy and the patients' presentation in our study ranged from few days to 3 months postoperatively, where 60.7% of patients presented within 1 week, which is lower than that recorded by Wu et al.

In this study, the most common presentations of postoperative BDI were obstructive jaundice with or without cholangitis followed by biliary leakage and intraperitoneal bile collection.

Our results are in accordance with those of Al Jiffry et al., but quite different from the results of Wu et al. where the most common presentation was bile leak through surgical drains, surgical wounds, or laparoscopic ports.[1],[2] Other common presentations recorded by many authors especially in a complex Strasberg type E injury include diffuse abdominal pain, nausea, fever, and bile collections with peritonitis, leukocytosis, and mixed hyperbilirubinemia.[11] Jaundice is not always present immediately as most of the Strasberg B and C type patients present with nonspecific symptoms such as abdominal pain, pruritus, general weakness, and fever.[5]

According to Al Jiffry et al., the initial evaluation of a biliary injury depends on imaging, such as ultrasonography and CT, which can detect the presence of fluid collection or ascites in the peritoneal cavity that is indicative of a bile leak in addition to USGA.[2] In the present study, ultrasound was used for the initial diagnosis of all cases, and USGA was used successfully in all patients with intra-abdominal biliary collection.

Most of the authors emphasized that ERCP in addition to its diagnostic effect facilitates the definitive management of several injuries with temporary internal stents.[1],[2],[7] In the present study, 100% of our patients performed ERCP; it was successful as a diagnostic modality; however, 78% of the cases developed hyperamylasemia and only 4.8% of ERCP patients developed pancreatitis. The findings of several studies were in accordance with our findings as they found that an elevation in the serum amylase is occurring in about 75% of patients who underwent ERCP and acute clinical pancreatitis which is defined as a clinical syndrome of abdominal pain, and hyperamylasemia requiring hospitalization was much less common and ranges from 4% to 9%.[8]

In the present study, ERCP was successful in 87.5% of cases as a therapeutic modality in Strasberg type A patients to stop biliary leak; however, in 12.5% of type A patients, open surgeries were required to ligate the stump of the cystic duct or to extract retained stone and to perform choledochoduodenostomy. Much lower rate of success was recorded in the study of Karabulut et al., where 62% of their patients successfully underwent diagnostic and therapeutic ERCP.[9] In the study of Al Jiffry et al., ERCP failed in 16.7% of patients with Strasberg type A to treat persistent bile leak by stenting and surgery was required to suture the gallbladder bed.[2] The lower failure rate in the present study compared with that in the Al Jiffry et al.'s study may be related to the smaller specimen number of the latter.

Most of the hepatobiliary surgeons prefer prompt surgical management once BDI is diagnosed, and all patients are taken to the operating room within the same week of hospital admission (after completing the preliminary workup) to avoid the development of dense adhesions.[2],[15],[16],[17] The same was done in our study. Some investigators recommended partial resection of segments IV and V in addition to the lowering of the hilar plate to preserve circulation and allow adequate duct exposure for the anastomosis with more room for the intestinal loop.[11],[17]

Al Jiffry et al. observed in their study that the anastomotic stricture rate decreased from 25% in the group of patients who underwent end-to-side H-J without lowering the hilar plate to 5% in the second group when the hilar plate is lowered and anterior right end-to-side with anterior left side-to-side RYHJ is performed.[2] In our study, 9.7% of patients who underwent this type of anastomosis developed anastomotic stricture and were treated successfully by percutaneous transhepatic cholangial dilatation. The higher figure of development of anastomotic stricture in our study than that recorded in Al Jiffry et al. study may be explained by the difficulty of the technique and that the learning curve is still developing in some hospitals involved in the study; however, our findings are much better than that recorded for the other techniques of HJ recorded in literature.


This study proved the safety and efficacy of the management of iatrogenic BDI by an expert team implementing different diagnostic and treatment modalities such as ultrasound, CT scan, and ERCP in addition to different surgical options, particularly the use of right end-to-side and left side-to-side RYHJ with lowering the hilar plate and anterior anastomosis.

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Conflicts of interest

There are no conflicts of interest.


1Wu JS, Peng C, Mao XH, Lv P. Bile duct injuries associated with laparoscopic and open cholecystectomy: Sixteen-year experience. World J Gastroenterol 2007;13:2374-8.
2Al Jiffry BO, Al Nemary Y, Niyaz HN, Elmakhzangy H, Hatem M. Bile duct injuries following laparoscopic cholecystectomy and repair involving lowering of the hilar plate. Saudi J Surg 2013;1:1-6.
3Azeemuddin M, Turab N Al Qamari, Chaudhry MB, Hamid S, Hasan M, Sayani R. Percutaneous management of biliary enteric anastomotic strictures: An institutional review. Cureus 2018;10:e2228.
4Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: A review. ANZ J Surg 2010;80:75-81.
5Mercado MA, Domínguez I. Classification and management of bile duct injuries. World J Gastrointest Surg 2011;3:43-8.
6Jabłońska B, Lampe P. Iatrogenic bile duct injuries: Etiology, diagnosis and management. World J Gastroenterol 2009;15:4097-104.
7Lillemoe KD. Current management of bile duct injury. Br J Surg 2008;95:403-5.
8Testoni PA, Mariani A, Giussani A, Vailati C, Masci E, Macarri G, et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and among expert and non-expert operators: A prospective multicenter study. Am J Gastroenterol 2010;105:1753-61.
9Karabulut M, Bas K, Gonenc M. Diagnosis and treatment of iatrogenic bile duct injuries. Med J Bakikroy 2012;8:116-22.
10Adler DG, Papachristou GI, Taylor LJ, McVay T, Birch M, Francis G, et al. Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: A large multicenter study. Gastrointest Endosc 2017;85:766-72.
11Gouma DJ, Obertop H. Management of bile duct injuries: Treatment and long-term results. Dig Surg 2002;19:117-22.
12Griswold BG, White JA. The fortuitous repair of a common bile duct injury following placement of a percutaneous transhepatic cholangiogram catheter. J Surg Case Rep 2017;2017:rjx 151.
13Lillemoe KD, Melton GB, Cameron JL, Pitt HA, Campbell KA, Talamini MA, et al. Postoperative bile duct strictures: Management and outcome in the 1990s. Ann Surg 2000;232:430-41.
14Sicklick JK, Camp MS, Lillemoe KD, Melton GB, Yeo CJ, Campbell KA, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: Perioperative results in 200 patients. Ann Surg 2005;241:786-92.
15Ahrendt SA, Pitt HA. Surgical therapy of iatrogenic lesions of biliary tract. World J Surg 2001;25:1360-5.
16Prasad A, De S, Mishra P, Tiwari A. Robotic assisted Roux-en-Y hepaticojejunostomy in a post-cholecystectomy type E2 bile duct injury. World J Gastroenterol 2015;21:1703-6.
17Winslow ER, Fialkowski EA, Linehan DC, Hawkins WG, Picus DD, Strasberg SM. “Sideways”: Results of repair of biliary injuries using a policy of side-to-side hepatico-jejunostomy. Ann Surg 2009;249:426-34.