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14 3D Visual Diagnosis andManagement ofBile Duct Injuries
Fig. 14.9 Relationship between dilated bile ducts and arteries
327
Fig. 14.11 Relationship between dilated bile duct and pancreas
Fig. 14.10 Relationship between dilated bile duct and portal vein
Fig. 14.12 Intraoperative titanium clips
Fig. 14.13 Common bile duct suture
328
Fig. 14.14 Opening of right hepatic duct, PTCD drainage duct, and
left hepatic duct
N. Zeng et al.
Fig. 14.16 Transverse rupture of distal common bile duct stump
Fig. 14.15 Exploration of the lower common bile duct
Fig. 14.17 Choledochointestinal anastomosis
14 3D Visual Diagnosis andManagement ofBile Duct Injuries
Fig. 14.18 Postoperative cholangiography showed that the bile duct
was in good circulation, the intrahepatic bile duct was not dilated, and
the contrast agent entered the intestinal cavity smoothly
329
14.2.2 Application of3D Visualization
Technique inBiliary Tract Injury
(Case2)
14.2.2.1 Patient Information
Female, aged 58 years.
14.2.2.2 Diagnosis
Common bile duct transection, post laparoscopic
cholecystectomy.
14.2.2.3 Complaint
Yellow skin for more than a week, no chills, fever.
14.2.2.4 History
The patient underwent laparoscopic cholecystectomy for
cholecystolithiasis in a hospital a week ago. Two days after
the operation, yellow uid was extracted through the drainage tube of the abdominal cavity, accompanied by the yellow
stain of the whole-body skin, no chills, and fever. ERCP
catheterization was performed in this hospital, and no bile
was extracted.
Fig. 14.19 3D reconstruction after surgery
14.2.2.5 Signs
Skin sclera has a slightly yellow stain. The abdomen is at
and soft; there is no tenderness or rebound pain in the whole
abdomen, and no palpable mass in the upper abdomen; liver
and spleen subcostal unreached; liver and kidney percussion
pain negative, bowel sound normal. No bile was induced in
the nasobiliary catheter. The celiac drainage tube leads to
bile-like uid, 100–150 ml/day.
14.2.2.6 Previous History
Laparoscopic cholecystectomy was performed 1 week before
due to cholecystolithiasis.
14.2.2.7 Laboratory Examination
Blood Routine
Leucocyte 8.32 × 109/L, neutrophil 80.5, erythrocyte 3.12 ×
109/L, hemoglobin 86 g/L, and other indicators are normal.
330
N. Zeng et al.
Coagulation Function
Activated partial thromboplastin time (APTT) was 25.0 s,
prothrombin time (PT) was 12.0 s, and thrombin time was
12.6 s. Fibrinogen 5.00 g/L, INR 1.02.
Liver Function
Albumin 36.3 g/L, ALT 140.8 IU/L, AST 86.8 U/L, DB 65.7
μmol/L, TB 79.5 μmol/L, AKP 551 U/L, γ-GT 542 U/L.
Renal Function
Normal.
Tumor Markers
Normal.
14.2.2.8 General Condition Assessment
Nutritional Status Evaluation
Patients weighed 52 kg, body mass index (BMI) = 20.0/L,
albumin 36.3 g/L, prealbumin 129.6 mg/L, nutritional risk
score 0.
Liver Function Evaluation
Child-Pugh grade A.
Important Organ Function Evaluation
There was no abnormal function of important organs such as
heart and lung.
anterior branch and left branch from the main branch
(type III).
• Bile Duct Conuence of the bile duct was normal (type I).
• Spatial Conformation of Hepatic Vasculature Right pos-
terior hepatic artery of superior portal vein type and the
right posterior hepatic duct of superior portal vein type
(Fig.14.20).
Location of the Lesion
The stricture ring of the bile duct
was located in the common hepatic duct, <2cm away from
the conuence of the right and left hepatic ducts (Fig.14.21).
Types ofBile Duct Stricture
• Bismuth type: type II.
• Strasberg type of bile duct stenosis: type E2.
• Chinese Medical Association bile duct injury and treat-
ment guidelines (version 2013): type II 1D injury.
14.2.2.10 Surgical Planning
This case was high bile duct stricture. The stricture ring was
located in the common hepatic duct and was <2cm away
from the conuence of the right and left hepatic ducts. The
continuity of the left and right hepatic ducts was observed.
The stricture ring of the high bile duct was resected, and
Roux-en-Y anastomosis of the hilar bile duct and jejunum
were performed.
14.2.2.11 Surgical Procedures
14.2.2.9 Imaging Evaluation
Enhanced CT Scan oftheUpper Abdomen
Enhanced CT scan of the upper abdomen showed that the
intrahepatic bile duct was dilated after cholecystectomy, the
upper segment of the common bile duct was not displayed,
and the drainage in the operative area was in progress.
MRCP oftheUpper Abdomen
MRCP of the upper abdomen showed that the intrahepatic
bile duct was dilated after cholecystectomy, the upper segment of the common bile duct and hilar bile duct was not
displayed, and drainage in the gallbladder fossa was in
progress.
Evaluation by 3D Visualization
Variation ofHepatic Portal Vessels
• Hepatic Artery Origin and course of the hepatic artery
were normal (Michel type I).
• Portal Vein Right posterior branch of portal vein rst
was issued from the main portal vein, then the right
Step 1
The intra-abdominal adhesions were separated; the common
bile duct was dissected. The hepatic artery, its branches, and
the portal vein, were carefully preserved during operation.
The common bile duct was transected, freeing the proximal
hepatic duct and lowering the hepatic portal panel to nd the
biliary stula (Fig.14.22).
Step 2
The scar tissue at the lower end of the proximal hepatic duct
was excised. The right anterior hepatic duct and the right
posterior hepatic duct opening were exposed to the right
hepatic duct by right incision; the transverse part of the left
hepatic duct was incised to the left. The hepatic hilum was
opened (Fig.14.23).
Step 3
The right anterior hepatic duct, right posterior hepatic duct,
and left hepatic duct were reconstructed into a hepatic duct
opening and anastomosed end-to-side with the distal jejunum through 5-0 PDS suture (Fig.14.24).
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14 3D Visual Diagnosis andManagement ofBile Duct Injuries
331
Fig. 14.20 3D visualization processing shows hepatic vessels. (a) The
hepatic artery runs normally, (b) The right posterior branch of the portal
vein is discharged rst from the main portal vein and then the trunk
issues the left and right anterior branches, (c) The bile duct conuence
pattern is normal; (d) Supraportal right posterior artery. Note: Hepatic
artery (red); Portal vein (blue); Bile duct (green)
14.2.3 Application of3D Visualization
Technique inBiliary Tract Injury
(Case3)
abdominal pain occurred about 1 month after the operation,
and radiated to the back, accompanied by chills and fever.
The body temperature was as high as 39.5 C.The symptoms
were alleviated after uid replacement and anti-infection
14.2.3.1 Patient Information
Female, aged 62 years.
therapy. Yellow skin at the time of the attack was denied. The
symptoms mentioned above have been recured more than 10
times in the past 7 years.
14.2.3.2 Diagnosis
Stricture of choledochojejunostomy, post-operation of cholecystectomy, and choledochojejunostomy.
14.2.3.5 Signs
There was no yellow stain on the sclera. The abdomen was
at and soft; there was no tenderness or rebound pain in the
14.2.3.3 Complaint
Recurrent right upper abdominal pain with chills, high fever
for more than 7 years.
14.2.3.4 History
The patient underwent cholecystectomy and jejunojejunostomy with Roux-en-Y anastomosis 7 years ago for cholecystolithiasis in another hospital. Recurrent right upper
whole abdomen, and no palpable mass in the upper abdomen; liver and spleen subcostal unreached; liver and kidney
percussion pain negative, bowel sound normal.
14.2.3.6 Previous History
Open cholecystectomy and choledocholithojejunostomy
(Roux-en-Y) was performed for cholecystolithiasis 7 years
ago.
332
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N. Zeng et al.
Fig. 14.21 Enhanced CT and 3D visualization processing show the
location of bile duct stricture. (a–c) Enhanced CT venous phase, repre-
processing. Note: Black arrow: bile duct dilation (a, b) and stricture (c)
in sequence. White arrow: bile duct stricture
senting the cephalic to caudal sequence images; (d) 3D visualization
Right posterior hepatic
duct opening
Proximal bile duct transection
Right anterior hepatic
duct opening
Left posterior hepatic
duct opening
Fig. 14.22 Separate upward and downward along the transverse section of the common bile duct to nd the bile leakage
Fig. 14.23 Reveal the right anterior hepatic duct opening, right posterior hepatic duct opening, and left hepatic duct opening
14 3D Visual Diagnosis andManagement ofBile Duct Injuries
The anastomotic stoma
Fig. 14.24 Choledochojejunostomy
14.2.3.7 Laboratory Examination
Blood Routine
Normal.
Coagulation Function
Normal.
Liver Function
Albumin 43. 7 g/L, ALT 22 IU/L, AST 20 U/L, DB 2.6
μmol/L, TB 19. 2 μmol/L, AKP 69 U/L, γ-GT 42 U/L.
Renal Function
Normal.
Tumor Markers
Normal.
14.2.3.8 General Condition Assessment
Nutritional Status Evaluation
Patients weighed 43 kg, body mass index (BMI) = 17.9 kg/
m2, albumin 43.7 g/L, prealbumin 240.10 mg/L, nutritional
risk score 0.
Liver Function Evaluation
Child-Pugh grade A.
333
motic stoma was unclear, and the right anterior lobe intrahepatic bile duct was slightly dilated.
MRCP oftheUpper Abdomen
MRCP of the upper abdomen showed that “after cholecystectomy” and “after choledochojejunostomy,” there was
stricture of choledochojejunostomy and slight dilatation
of intrahepatic bile duct in the right anterior lobe of the
liver.
Evaluation by 3D Visualization
Variation ofHepatic Portal Vessels
• Hepatic Artery Origin and course of the hepatic artery
were normal (Michel type I).
• Portal Vein The course of the portal vein was normal
(type I).
• Bile Duct The conuence of the bile duct was normal
(type I).
• Spatial Conformation of Hepatic Vascular Subportal right
posterior hepatic artery, and subportal hepatic right posterior bile duct (Fig.14.25).
Location of the Lesion
The stricture ring of the bile duct
is located in the common hepatic duct, <2cm away from
the conuence of the left and right hepatic ducts
(Fig.14.26).
Types ofBile Duct Stricture
• Bismuth type: type II.
• Strasberg type of bile duct stenosis: type E2.
• Chinese Medical Association bile duct injury and treatment guidelines (version 2013): type II 1 d injury.
14.2.3.10 Surgical Planning
This case was high biliary stricture. The stricture ring was
located below the conuence of the left and right hepatic
ducts, <2cm away from the conuence. The left and right
hepatic ducts were continuous. The anastomotic stoma was
resected, the high biliary stricture ring was resected. The
hepatic hilar bile duct was anastomosed with jejunum Rouxen- Y after a plastic operation.
14.2.3.11 Surgical Procedure
Important Organ Function Evaluation
There was no abnormal function of important organs such as
heart and lung.
14.2.3.9 Imaging Evaluation
Enhanced CT Scan oftheUpper Abdomen
Enhanced CT scan of the upper abdomen showed that after
cholecystectomy and choledochojejunostomy, the anasto-
Step 1
The intraperitoneal adhesion was separated, and the anterior
wall of choledochojejunostomy was exposed. The hepatic
artery and its branches and portal vein were protected carefully. After the proximal bile duct was conrmed by puncture, the anastomosis of the primary bile duct was cut off,
and the opening of the proximal bile duct could pass a 2-mm
silicon tube (Fig.14.27).
334
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N. Zeng et al.
Fig. 14.25 3D visualization processing shows hepatic vessels. (a) The
hepatic artery runs normally, (b) The portal vein runs normally; (c) Bile
duct conuence is normal; (d) Right posterior hepatic artery coursing
Step 2
Lower the hepatic portal plate. The transverse part of the left
transverse tube to the sagittal part of the portal vein was cut
to the level of the portal vein. The opening of the proximal
bile duct was cut to the left side by about 1.5cm. The opening of the left hepatic duct was enlarged, and the prolene line
and bile mud in the left hepatic duct was removed (Fig.14.28).
Step 3
The right hepatic duct was opened to the right anterior
hepatic duct, and the right posterior hepatic duct was
explored without stenosis. The right anterior hepatic duct,
right posterior hepatic duct, and left hepatic duct were
alongside the inferior portal vein, inferior portal vein alongside the posterior hepatic duct. Note: Hepatic artery (red); Portal vein (blue); Bile
duct (green)
reformed and anastomosed with the jejunum of the original
loop with 5-0 PDS line (Fig.14.29).
Iatrogenic bile duct injury is a serious problem in biliary
surgery, which can bring serious and difcult consequences
to patients, such as recurrent biliary infection, biliary cirrhosis, liver failure, and even liver transplantation. Therefore, it
is imperative to actively prevent iatrogenic bile duct injury.
• The surgeons should strengthen their sense of responsibility, treat every case of cholecystectomy seriously, and
strengthen their vigilance with regard to anatomical variation and local pathological factors of the bile duct
system.
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14 3D Visual Diagnosis andManagement ofBile Duct Injuries
335
Fig. 14.26 Contrast-enhanced CT and 3D visualization processing
show the location of bile duct stricture. (a), (b), and (c) display contrastenhanced CT scans obtained during venous phase; a–b–c represents the
• Good exposure of the surgical field should be maintained during the operation, and the anatomical relationship among the cholecyst duct, the common
hepatic duct, and the common bile duct should be confirmed before ligation and transection of the gallbladder duct.
• The cholecystic duct should be kept in a tension-free condition when the gallbladder duct is ligated, and the ligation line should be 0.5cm away from the wall of common
bile duct.
• Use of an Electric knife is forbidden to stop bleeding or
separate tissues near the bile duct, so as to prevent heatinduced injury of bile duct.
cephalic to caudal sequence images; (d) shows 3D visualization processing. Note: Black arrow: showing bile duct (a, b) and the stricture
site (c) in sequence. White arrow: bile duct stricture
tectomy should be transferred to laparotomy in a timely
manner when it is necessary.
• In case of abnormal bleeding of gallbladder artery, the left
nger and thumb can be placed in front of the lesser
omentum foramen and hepatoduodenal ligament, respectively. The hepatic artery can be pressed to stop bleeding.
After the hemorrhage is halted, release the nger pressure,
and see the bleeding point, then clamp ligation or suture
is performed to stop the bleeding. Avoid blindly clamping
in a “blood pool.”
• Retrograde cholecystectomy or partial cholecystectomy
should be performed if the removal of the gallbladder by
the anterograde method is difcult.
• Avoid excessive stripping of tissues around the bile duct
and protect vascular plexus around it in order to avoid
ischemic injury of the bile duct; Laparoscopic cholecys-
The cases as mentioned above conrmed that the 3D visu-
alization technique could (a) accurately display the location
336
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The proximal bile
duct
The anterior wall of the anastomotic stoma
Fig. 14.27 The hilar choledochojejunostomy was exposed and cut off. (a) Exposure of the anterior wall of the choledochojejunostomy; (b) Place
the silicone tube into the proximal bile duct
Silicon tube
N. Zeng et al.
The prolene line and bile mud
inside the left hepatic duct
The anastomotic stoma
Fig. 14.28 Cut the left transverse hepatic duct to the left side, and take
out the prolene line and bile mud inside the left hepatic duct
Fig. 14.29 Left and right hepatic ducts were reshaped, and jejunum of
the original input loop was anastomosed
of high-level injured bile duct stenosis, (b) guide the clinical
judgment of the anatomical pathway of the bile duct, hepatic
artery, and portal vein, (c) design and implement optimal
repair and treatment programs, and (d) avoid secondary injuries caused by reoperation.
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