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FIGURE 7.20. Trocar placement in laparoscopic cholecystectomy.
The gallbladder fundus is grasped with a forceps and the
assistant elevates it toward the left shoulder. Another
forceps grasps Hartmann’s pouch and retracts it laterally.
This move is critical to open the triangle of Calot. The
surgeon then dissects the cystic artery and cystic duct as it
leaves the gallbladder. The cystic duct is traced down to its
entrance into the CBD.Once these structures are identified,
the cystic artery and duct are clipped and divided, and the
GB is dissected off from the liver bed toward the fundus.
While this infundibular technique of cholecystectomy
is the most popular, some surgeons consider it unsafe
because the cystic artery and duct, and the CBD, common
hepatic duct, and right hepatic duct cannot be identified
with enough confidence to reduce the possibility of damage
to near zero. Strasberg et al. have advocated that, once the
structures thought to be the cystic duct and cystic artery
are identified, dissection should be carried out from the
fundus down to the infundibulum.
7
Only after the GB is
removed is it then optimally safe to divide the cystic artery
and duct. Whenever there is any doubt about the anatomy,
an operative cholangiogram should be obtained through
the cystic duct or the gallbladder. Routine cholangiogram
is advocated by some and not performed by most.
Placement of a drain in the right subhepatic space is not
usually necessary.The nasogastric tube and urinary catheter
are removed at the end of the procedure. Most patients stay
overnight in the hospital, but increasingly patients are being
discharged home on the day of operation. On average, the
mean return to work period is 6 days.
Less commonly, transverse, right paramedial, or the Kehr
incisions may be used.
After general anesthesia is administered, a nasogastric
tube and urinary catheter are inserted and the abdomen
opened. Following general abdominal exploration, the
gallbladder and CBD are exposed. Any omental adhesions
to the gallbladder fundus are divided, and the gallbladder
is lifted off the transverse colon. The hepatic flexure and
stomach are packed away laterally. If the gallbladder is
tensely distended, it may be decompressed by inserting a
suction cannula through a stab wound using a pursestring suture. The fundus and the Hartmann pouch are
then clasped with a hemostat and a long forceps, respectively. Key to obtaining adequate exposure are: (1) retraction of the gallbladder upward and laterally using the two
forceps, (2) retraction of the liver upwards and slightly to
the left using a sponge-covered Deaver retractor, and (3)
retraction of the distal CBD and duodenum inferiorly by
the assistant’s left hand.
The dissection begins at the triangle of Calot, which is
opened by laterally retracting Hartmann’s pouch and
upwardly displacing the liver. The cystic artery normally
crosses the triangle of Calot and courses up onto the gallbladder, where it starts to divide. Inferior retraction of the
CBD and lateral retraction of Hartmann’s pouch brings
into prominence the cystic duct. Silk sutures (2–0) are
applied around the cystic artery and cystic duct, but the
structures are left undivided. The safest procedure is now
to dissect the gallbladder down from fundus to infundibulum. When this dissection is completed, the gallbladder is
free and remains attached by the cystic duct and cystic
artery. These structures can now be divided safely between
ligatures of 2–0 silk. The cystic duct is divided 3 to 5mm
from its junction with the CBD.
If an operative cholangiogram is to be performed, it is
best to do it after the gallbladder is completely removed
Open Cholecystectomy
The incisions and exposure techniques used in open cholecystectomy are illustrated in Figure 7.21. The most
common incisions used are right subcostal or midline.
C linical D isorders.............................................................................................................................. 219
FIGURE 7.21. Choice of incisions for open cholecystectomy.
220 .................................................................................................................................... Biliary T ract
from the liver with the cystic duct intact. A catheter can
easily be inserted into the cystic duct near its junction with
the gallbladder.
The primary disadvantage of the fundus-toinfundibulum dissection technique is that more blood
oozes because the cystic artery has not been ligated. This
disadvantage is more than compensated for by the safety of
the procedure, which makes an inadvertent division of the
CBD, common or right hepatic ducts virtually impossible.
Most surgeons place a closed drainage catheter in the
infrahepatic space, but this practice is not always necessary.
Cholecystostomy
Cholecystostomy can be performed either laparoscopically
or with the open technique. In either case, a pursestring
suture is applied to the fundus of the gallbladder, and a
catheter (e.g., #16 Foley) is introduced through a stab
wound within the pursestring suture. The pursestring
suture is securely tied after the balloon of the Foley
catheter is inflated and pulled up to the stab wound. It is
wise to suture the gallbladder fundus to the peritoneum
after the catheter is exteriorized through a stab wound in
the abdominal wall. The subhepatic space is routinely
drained with closed catheter suction.
Unusual Treatment Circumstances
The inflammatory response, particularly near the junction
of the cystic and common hepatic ducts, may be so intense
that the cystic duct cannot be identified. If so, the choices
are to perform cholecystostomy and close, or to start dissection from the fundus downward to see if the anatomy
can be better delineated to enable safe division of the cystic
duct. If not, cholecystostomy should be performed.
In severe acute cholecystitis with gangrene of the
fundus and body, the cystic duct and artery may not be
identifiable because of the inflammatory response. In this
case, it may be feasible to perform partial cholecystectomy,
remove all calculi from the remaining portion of the gallbladder and close the remnant over a Foley catheter using
a pursestring suture. The Foley should be passed through
the abdominal wall before it is inserted into the gallbladder remnant. The pericholecystic area should always be
drained with a suction catheter.
OBSTRUCTIVE JAUNDICE DUE
TO STONES
The main symptom of stones in the CBD is obstructive
jaundice. This is often associated with pain, which tends
to be upper midline in distribution and aggravated by
eating. Intermittent, painful jaundice is usually due to
stones and not carcinoma. The dreaded complications are
cholangitis and pancreatitis, which are discussed elsewhere. The patient may or may not have had cholecystectomy previously.
Investigations
Liver functions tests show direct hyperbilirubinemia and
elevated alkaline phosphatase with minimal or no abnormality of hepatocellular function. The ultrasonogram
shows a dilated CBD (>6mm diameter) and sometimes
stones within the duct (Figure 7.13). More definitive evaluation of the CBD is provided by either MRC or ERCP.
Although MRC is noninvasive, ERCP provides the additional advantage of performing sphincterotomy and
removing common duct stones.
Treatment
Choledocholithotomy
Common bile duct stones may be removed with ERCP,
laparoscopy, or open surgery. The essentials of treatment
are summarized in Table 7.9.
ERCP
Endoscopic sphincterotomy and removal of common duct
stones using forceps, baskets, or balloons has proven safe
and effective. It has a mortality rate of 0.5% to 1.0% and
a morbidity rate of 8% to 10%. It is primarily indicated in
the following conditions:
1. Retained stones or stones developing in the CBD
after previous cholecystectomy.
2. Severe biliary pancreatitis, where therapeutic ERCP
within the first few days of attack has reduced the incidence of mortality to a tenth of what it was.
3. Severe ascending cholangitis, where the patient is
extremely ill and the CBD can be decompressed quickly.
4. Planned operation in a patient with stones in both
gallbladder and CBD,in which preoperative clearing of the
TABLE 7.9. Essentials: Treatment of Choledocolithiasis
Gallbladder intact
䊏
Preferred approach: Laparoscopic cholecystectomy and
choledocolithotomy
䊏
Alternatives if laparoscopic choledocolithotomy is unsuccessful
Open choledocolithotomy
Postoperative removal by ERCP
Gallbladder previously removed
䊏
Preferred approach: Endoscopic papillotomy and
choledocolithotomy
䊏
Alternatives:
If preferred approach is unsuccessful, open CBD
exploration and choledocolithotomy
If stone cannot be removed via choledocolithotomy,
duodenotomy, and sphincteroplasty
Too many CBD stones
䊏
End-to-side Roux-en-Y choledocojejunostomy
䊏
Choledocoduodenostomy
Abbreviation: CBD, common bile duet; ERCP, endoscopic retrograde
cholangiopancreatography.
CBD by ERCP allows laparoscopic cholecystectomy and
operative cholangiogram to be done without the need to
explore the CBD.
Laparoscopic CBD Exploration and
Choledocholithotomy
The experienced laparoscopist can explore the CBD and
remove stones through the cystic duct or after choledochotomy at the time of laparoscopic cholecystectomy.
Choledochoscopy can also be performed, allowing direct
examination of the extrahepatic biliary tract. The safety
and success rate of laparoscopic choledocholithotomy is
directly related to the experience of the surgeon and must
not be attempted by the person who performs laparoscopy
infrequently.
The procedure is indicated:
1. When, in the course of laparoscopic cholecystectomy,
stones are discovered in the CBD, a situation that
obtains in 10% to 15% of cases.
2. When preoperative ERCP has failed to cannulate the
ampulla in patients known to have CBD stones.
Open CBD Exploration
It is imperative that every biliary tract surgeon maintain
his or her ability to perform open exploration of the CBD.
Clearly, the frequency with which this operation is performed has declined as more and more CBD stones are
removed by ERCP or laparoscopically. However, the procedure is still the gold standard by which the successes,
failures, and morbidity and mortality of other techniques
must be judged.
The procedure is performed either in conjunction with
open cholecystectomy or, in the patient with retained
stones, after previous cholecystectomy, especially where
ERCP has failed and the laparoscopic approach is either
not available or deemed too difficult because of adhesions.
The approach is usually through a right subcostal or
midline incision. In patients who still have their gallbladder, cholecystectomy is first performed and identification
of the CBD is not difficult. In patients who have had prior
cholecystectomy, however, careful dissection of the structures in the subhepatic fossa is required. The CBD is normally to the right of the common hepatic artery and
anterior to the portal vein. When a structure that resembles the CBD is identified, it is confirmed by aspiration of
bile with a 21-gauge needle on a syringe. The CBD is then
dissected and a suitable place for choledochotomy chosen.
The best location is just distal to the entrance of the cystic
duct but in the supraduodenal part of the structure. Two
stay sutures of 3–0 silk are applied to the anterior wall, and
the duct is opened between the sutures for about 2cm.
At times, stones are immediately visible and can be
removed by irrigation. Some surgeons prefer to perform
choledochoscopy early, others later. One simple procedure
to follow is to start by irrigating the CBD, both below and
above the incision, using a red rubber catheter (#10 or
FIGURE 7.22. This intraoperative cholangiogram, performed
during a laparoscopic cholecystectomy, shows a normal common
bile duct and common hepatic duct. It is often difficult to fill the
intrahepatic ducts with contrast when the sphincter of Oddi
relaxes, as it does here (arrow). (Courtesy of Henry I. Goldberg,
MD.)
#12). The maneuver may result in removing all or most of
the floating stones. Next, a biliary Fogarty catheter is
passed distally and, if possible, into the duodenum. The
balloon is inflated and pulled snug against the ampulla.
The balloon is then deflated slowly as it is pulled up
through the sphincter. As soon as the give is felt, the
balloon is inflated, pulled up and out of the choledochotomy. If this procedure is unsuccessful after two or
three attempts, stone forceps and/or Dormia baskets are
used. Several applications of these procedures alternated
with liberal saline irrigation may be required. The proximal extrahepatic biliary tract must also be explored both
by balloon catheter and stone forceps, if necessary.
It is helpful to know before exploration how many
stones there are, but even after removing the expected
number of stones, completion cholangiogram and/or
choledochoscopy is essential (Figure 7.22). When the CBD
has been satisfactorily cleared of stones, the choledochotomy is closed after inserting a T-tube. The closure is
accomplished with absorbable 4–0 sutures, ensuring that
the T-tube is not kinked inside the duct. The transverse
portion of the T-tube often needs to be bivalved or the
inferior half excised to facilitate its removal from the duct
when the time comes. A closed suction-drain is placed in
the right subhepatic fossa.
OSTOPERATIVE CARE OF THE T-TUBE The T-tube is
P
allowed to drain freely into a bag. The amount of drainage
decreases with time. A T-tube cholangiogram may be
obtained safely after postoperative day 7. If no residual
stones are seen and dye flows freely into the duodenum, the
T-tube is clamped. It is unclamped only if the patient
C linical D isorders.............................................................................................................................. 221
develops pain; otherwise, it is kept clamped until its
removal in the office at about 3 weeks, when a well-formed
tract has developed. If a retained stone had been identified,
it can be removed through this T-tube tract.
Unusual Circumstances
IMPACTED STONES In some cases, impacted stones
may be located at the distal end and cannot be removed
from above. The prudent thing to do in this case is to open
the second portion of the duodenum over the ampulla and
perform sphincterotomy to remove the stone either from
below or by dislodging it upwards. The technique of
sphincterotomy is depicted in Figure 7.23. The other alternative is intraoperative or postoperative ERCP.
OO MANY STONES When stones are too numerous to
T
extract, the prudent procedure is to perform either a choledochoduodenostomy or Roux-en-Y choledochojejunos-
A
B
FIGURE 7.23. Dislodgement of impacted stone in GB via sphincterotomy. (A) Open sphincterotomy is
accomplished via duodenotomy and the sphincter is incised at 11 o’clock. (B) The open edges are then
kept open by interrupted sutures. (Adapted from Blumgart LH. Surgery of the Liver and Biliary Tract,
2nd ed. New York: Churchill Livingstone, 1994:846–847.)
222 .................................................................................................................................... Biliary T ract
FIGURE 7.24. End-to-side or side-to-side Roux-en-Y choledochojejunostomy.
tomy (Figure 7.24). The choice depends on anatomy, age
and condition of the patient. An end-to-side Roux-en-Y
choledochojejunostomy is preferred, since it has a lower
long-term incidence of stricture or cholangitis. A side-toside Roux-en-Y choledochojejunostomy should not be performed because it is associated with development of the
sump syndrome, in which the distal portion of the CBD
acts as a collection vestibule for debris and infection.
IANT STONE IN THE
G
CBD On occasion, a large stone
wedged in the CBD cannot be moved up or down. Two
techniques may be used in conjunction with one another
or with a T-tube to address this problem:
1. Stone fragmentation by extracorporeal short-wave
lithotripsy (ESWL) has been effective in fragmenting
stones in over 90% of 56 patients in a multicenter trial.
2
2. Stone dissolution with chemicals such as monooctanoin and MBTE has been used successfully to dis-
associated risks of MBTE are less well known than those
of monooctanoin.
When a T-tube is in place in the management of these
giant stones, ESWL can be used to fragment the stones,
with subsequent dissolution through octanoic acid infusion into the T-tube or extraction using a Dormia basket
through the T-tube tract.
CHOLANGITIS
The disease occurs with a spectrum of severity. In mild or
moderate disease, the predominant symptoms are abdominal pain, fever and chills, and jaundice. These three symptoms coexist as Charcot’s triad in only 60% of patients. In
severe cholangitis, constituting about 5% of all cases of
cholangitis, the patient may demonstrate Reynold’s pentad
of symptoms, which include Charcot’s triad plus septic
shock and mental obtundation. RUQ or epigastric tenderness is common.
Investigations
Laboratory Tests
Leukocytosis with a shift to the left occurs in most
patients, as does hyperbilirubinemia and elevated serum
levels of aspartate aminotransferase (AST), alanine
aminotransferase (ALT), and alkaline phosphatase. The
presence of leukopenia carries a poor prognosis. Bilirubin
levels vary from a mean of 6.6 mg% in calculous disease to
over 15mg% when the cause is malignant obstruction.
The serum amylase level is elevated in about one-third and
often suggests benign calculous disease as the cause. Blood
cultures should be obtained, particularly during attacks of
fever and chills.
Imaging Studies
Abdominal ultrasound may show a dilated CBD (>6mm),
but cholangiography—either transhepatic (THC) or
ERCP—is necessary to establish the diagnosis and the
cause of obstruction. Diagnostic cholangiography should
be postponed until fever resolves and should be done only
under systemic antibiotic coverage. Both PTH and ERCP
can be used to provide internal or external drainage of the
biliary tract. When calculous disease or distal CBD
obstruction is suspected, ERCP is preferred because it
facilitates performance of endoscopic papillotomy, which
may provide temporary or permanent relief.
C linical D isorders.............................................................................................................................. 223
224 .................................................................................................................................... Biliary T ract
Treatment
Supportive therapy consists of nasogastric suction, intravenous fluids, intravenous broad-spectrum antibiotics,
and vitamin K to correct any subclinical coagulopathy.
Antibiotics that cover both Gram-negative and anaerobic
bacteria should be given. A popular initial choice is a combination of ampicillin, an aminoglycoside, and metronidazole. Subsequently, the choice of antibiotics is
determined from the results of culture and sensitivity
studies. Good response to antibiotic therapy occurs in
approximately 85% to 90%, permitting the performance
of definitive treatment on an elective basis. In those 10%
to 15% of patients who fail to improve, bile duct decompression is urgently needed. Endoscopic papillotomy and
nasobiliary drainage (alone or in combination) are preferable to emergency surgical exploration of the CBD. In a
prospective, randomized trial, Fan et al. demonstrated that
endoscopic decompression has lower morbidity (34% vs.
66%, p <0.05) and mortality (10% vs. 32%, p <0.03) rates
than surgical exploration.
3
Patients initially treated endoscopically on an urgent
basis or those who had a good response to medical therapy
require subsequent definitive treatment, depending on
what the urgent procedure was and whether or not they
still have a gallbladder. Patients who have had nasobiliary
drainage alone and prior cholecystectomy may be definitively treated with elective ERCP and endoscopic papillotomy. Those who still have a gallbladder with calculous
disease may be treated with endoscopic papillotomy and
subsequent laparoscopic cholecystectomy or with laparoscopic cholecystectomy and common duct exploration.
Open cholecystectomy and common duct exploration may
be necessary on rare occasions.
In patients who are critically ill from toxic cholangitis
in whom endoscopic drainage is technically not possible,
common duct decompression may be obtained by either
the percutaneous transhepatic route or laparoscopically.
When cholangitis is associated with malignant obstruction, the appropriate palliative or curative procedure is
required once the acute cholangitis is treated. When the
patient has an inoperable tumor, the common duct may
be drained via an internal stent placed either with ERCP
or transhepatically. Such stents may require repeated
replacement because of blockage with sludge.
GALLSTONE ILEUS
Acute, intermittent attacks of small bowel obstruction
over several days are the dominant clinical presentation of
gallstone ileus. A history suggestive of acute cholecystitis
may or may not be present. The picture is initially that of
high small bowel obstruction associated with abdominal
pain and frequent vomiting but successively becomes that
of middle and lower small bowel obstruction as the stone
moves distally to lodge at the ileocecal valve. These intermittent attacks of small bowel obstruction may last a few
to several days and, by the time the patient presents, significant dehydration and electrolyte imbalance may have
occurred. As a result, the patient, who is often elderly, may
be critically ill.
Investigations
Laboratory Tests
A high hematocrit level may be present as a result of dehydration. Depending on how severe the high small bowel
obstruction has been, electrolyte imbalance may be present with hypokalemia and metabolic alkalosis.
X-ray Studies
Definitive diagnosis may be established by plain abdominal films, which show mechanical small bowel obstruction
with air-fluid levels and air in the biliary tree (Figure 7.11).
Treatment
Nasogastric suction is initiated, the fluid and electrolyte
imbalance rapidly corrected, and surgery performed to
relieve the obstruction. The steps in the operation include:
1. Identification of the obstructing stone at the ileoce-
cal valve.
2. Removal of the stone through an enterotomy performed in healthy ileum at a point proximal to the site of
obstruction, which may be bruised and edematous.
3. Running the small bowel back to the region of the
cholecystoduodenal fistula to look for additional large
stones, in transit or in the gallbladder, which, if present,
are milked distally and removed through the enterotomy.
4. Closure of the enterotomy in two layers.
5. No attempt to take down the cholecystoduodenal
fistula or perform cholecystectomy.
In most patients, no further treatment of the biliary
tract disease is necessary. In some patients, because of persistent biliary tract symptoms, cholecystectomy is necessary. If at the time of cholecystectomy a fistula is still
present, it needs to be taken down and the duodenum
closed in two layers.
BILIARY PANCREATITIS
This topic is covered extensively in Chapter 4 under the
section entitled Acute Pancreatitis.
BILIARY TRACT INJURY
The mechanisms by which laparoscopic biliary tract injury
may occur are described in Table 7.10. Injuries vary from
relatively simple bile leak from the gallbladder bed to
incomplete or complete transection of the CBD, right
hepatic duct, or common hepatic duct. A useful clinical
classification of laparoscopic biliary tract injury from
C linical D isorders.............................................................................................................................. 225
TABLE 7.10. Classification of Causes of Laparoscopic Biliary
Injuries
Misidentification of bile ducts as cystic duct
䊏
Common hepatic duct
䊏
Aberrant right hepatic duct
Technical causes
䊏
Failure to securely occlude cystic duct
䊏
Plane of dissection too deep on liver bed
䊏
Injudicious use of thermal energy
䊏
Tenting injury of cystic duct
䊏
Injudicious use of clips
䊏
Improper technique of ductal exploration
Strasberg and colleagues7is given in Figure 7.25 and
Table 7.11. As is evident from the classification, not all
injuries lead to biliary stricture. Postoperatively, biliary
tract injury may become clinically manifest within days,
weeks, or months.
Strictures
Benign Biliary Strictures
Most benign strictures of the extrahepatic bile ducts are
due to iatrogenic injury,with 95% due to operative trauma.
The incidence of operative injury of the bile ducts rose
rapidly with the general adoption of laparoscopic cholecystectomy in the late 1980s and early 1990s.Since then, the
incidence has declined significantly as laparoscopic techniques have improved and experience has increased, but
the incidence of operative bile duct injury at present is still
higher than in the prelaparoscopic era. Other causes of
benign stricture include sclerosing cholangitis, chronic
pancreatitis, and blunt or penetrating abdominal trauma.
The management algorithm is shown in Figure 7.26.
Postoperative Bile Duct Strictures
Most bile duct injuries occur as a result of operations on
the GB or CBD. When surgery for complicated duodenal
ulcer disease was common, the CBD was occasionally inadvertently divided or sutured during difficult gastrectomy or
suture-control of a bleeding duodenal ulcer in cases where
the first portion of the patient’s duodenum had been significantly foreshortened by scarring. Because, at present,
most injuries occur in the course of laparoscopic cholecystectomy, the following discussion focuses on this mechanism of injury.
Bile duct injuries during cholecystectomy are due to
either misidentification of structures or errors of technique. Either the CBD or the right hepatic duct may be
misidentified as the cystic duct and divided. A common
error is to retract the infundibulum of the gallbladder vertically upwards. This maneuver aligns the cystic duct with
the CBD, and the latter structure is mistaken for the cystic
duct. This is especially so in young women and when the
CBD is small. In other situations, the right hepatic duct or
common hepatic duct may be entered through the gallbladder bed. Errors of technique include excessive bleed-
ing and misuse of cautery. The application of clips to
control bleeding when the ductal anatomy is not clearly
visible is another cause of injury. Aberrant bile ducts may
be inadvertently divided.
Postoperative leak from inadvertent bile duct injury
must be distinguished from bile leak caused by small
accessory ducts in the bed of the gallbladder or a slipped
ligature of the cystic duct.
Clinical Presentation
Early Presentation
Patients with bile leak usually present symptoms early,
either because of excessive bile in suction drainage or
because of accumulation of bile in the subhepatic space
(biloma), which may cause malaise, pain, and fever within
days of the operation. Bile leak may occur from accessory
bile ductules in the bed of the gallbladder, from slipped
cystic duct ligature, or from partial or complete transection of the CBD, the right hepatic duct, or the common
hepatic duct. Acute free biliary peritonitis is rare.
Late Presentation
When the common bile duct is mistaken for the cystic duct
and is transected, it is usually transected both distally and
proximally to the cystic duct. If both ends are ligated, no
bile leak occurs. Although most of these patients present
with progressive elevation of bilirubin and jaundice,
usually within weeks, it may take months for the situation
to be fully recognized. The diagnosis of traumatic stricture
of the bile ducts is established in approximately 70%
within 6 months and over 80% within 12 months. Occasionally, the diagnosis is made 2 to 5 years after surgery.
Management
Postoperative Bile Leak
When no drain is present, the diagnosis of bile leak should
be suspected in the patient who develops malaise, RUQ
pain, and fever. An ultrasonogram of the subhepatic space
shows the presence of bile collection, which is readily
drained with a percutaneously introduced catheter. Next,
the leak site must be identified. If bile drainage subsides
rapidly, no further investigation may be necessary. Introduction of contrast material through the drain catheter
can sometimes identify the site of leakage. Otherwise, the
best diagnostic technique is ERCP. Further management
depends on three possible ERCP findings:
1. If the biliary tract is intact without evidence of injury
or bile leak, the presumptive evidence is that leakage is
from the gallbladder bed. The only treatment required is to
continue catheter drainage until the drainage subsides.
2. If the biliary tract is intact but the cystic duct is
leaking, the treatment is endoscopic stenting of the bile
duct and continued drainage of the subhepatic space. The
cystic duct closes with time.
FIGURE 7.25. Strasberg’s classification of laparoscopic injuries to the biliary tract shows injuries Type
A to E. The E injuries are subdivided according to the Bismuth classification. Type A injuries originate
from small bile ducts that are entered in the liver bed or from the cystic duct. Type B and C injuries
almost always involve aberrant right hepatic ducts. Type A, C, D, and some E injuries may cause
bilomas or fistulas. Type B and other type E injuries occlude the biliary tree and bilomas do not
occur. (Adapted with permission from Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of
biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–125.)
226 .................................................................................................................................... Biliary T ract
FIGURE 7.25. Continued
3. If the common bile duct or the right hepatic duct has
been transected, the key steps are to ensure adequate
drainage of bile leak and to control sepsis with broadspectrum antibiotics. Besides external drainage of the subhepatic space, internal biliary drainage by the percutaneous
which accurately establishes the site of injury. It is crucial
that the patient be covered with broad-spectrum antibiotics
prior to THC and that, if possible, the procedure not be done
in the presence of cholangitis. The transhepatic route may
also be used to decompress the biliary tract with a catheter.
transhepatic route may be necessary. Once this is accomplished, surgery may be planned electively at a later date.
When a patient presents late after surgery, diagnosis
of bile duct stricture is established first by ultrasonography,
which shows dilated intrahepatic bile ducts and no visualization of the CBD. The next most useful investigation is THC,
C linical D isorders.............................................................................................................................. 227
Surgical Repair
Immediate Intraoperative Repair
Partial transection of the bile duct can be repaired primarily using fine absorbable sutures. Closed drainage of
228 .................................................................................................................................... Biliary T ract
the subhepatic space should be instituted. Depending on
the extent of laceration, T-tube drainage of the CBD may
be required.
When the common duct is completely transected,
primary repair has a high failure rate, even when the
surgeon feels the anastomosis can be done without
tension. The safest procedure is a Roux-en-Y hepaticojejunostomy, primarily with mucosa-to-mucosa anastomosis using fine absorbable sutures. Optical magnification is
useful, particularly when the bile duct is small.
Delayed Elective Repair
Critical in elective repair of established stricture are an
experienced surgeon and accurate anatomic definition of
injury preoperatively. This is especially true in high hilar
injuries when the remnant hepatic duct is short or absent,
necessitating separate anastomosis of both the left and
right hepatic ducts to the Roux-en-Y jejunal limb. When
an adequate length of the common hepatic duct is not
available, long-term stenting of the biliary-enteric anastomosis is necessary.
SCLEROSING CHOLANGITIS
In sclerosing cholangitis, progressive fatigue, pruritus, and
jaundice develop insidiously over 2 to 3 years. In some
patients, the diagnosis is made incidentally due to blood
tests or ERCP. Physical examination is either negative or
demonstrates hepatosplenomegaly and jaundice. The
histopathology shows replacement of bile ducts by dense
scarring, sometimes referred to as the disappearing duct
syndrome (Figure 7.27).
Investigations
Laboratory Tests
Alkaline phosphatase is usually elevated twofold or higher.
Serum bilirubin and transaminase levels are mildly increased. Increased levels of circulating immune complexes
and immunoglobulin M (IgM) are seen in 80% and 50%
of patients, respectively. Antineutrophil cytoplasmic antibody with a distinct perinuclear pattern (pANCA) is
present in over 80%. Serum copper levels are elevated in
49% of patients and ceruloplasmin levels in 71%.
Radiologic Assessment
Cholangiography—by the transhepatic route, ERCP or
MRC—is diagnostic. ERCP and MRC are the preferred
methods. Both intra- and extrahepatic ducts are involved,
particularly the hepatic duct bifurcation. The typical findings are multifocal strictures, which are short (1–2cm),
alternating with slightly dilated ducts, giving a beaded
appearance (Figure 7.12). The incidence of cholangiocarcinoma is as high as 10%. Other imaging techniques such
as ultrasound, CT, or scintigraphy are not as useful as
ERCP and MRC.
Treatment
Medical Treatment
All fat-soluble vitamins (A, D, E, and K) must be replaced.
Pruritus is treated with cholestyramine, activated charcoal,
phenobarbital, and ursodeoxycholic acid. Medical treatment of the primary disease involves immunosuppression
with corticosteroids and/or azathioprine.
Surgical Therapy
Biliary stricture may be managed by endoscopic bile duct
dilatation or stenting, but severe cases of extrahepatic
stricture require resection and hepaticojejunal Roux-en-Y
reconstruction. Any associated intrahepatic strictures can
be managed by percutaneous insertion of silastic stents.
The incidence of cholangiocarcinoma in ducts with sclerosing cholangitis is 7% to 15%. Resection of the involved
common bile duct reduces this risk. Surgical proctocolectomy may be required for associated ulcerative colitis, but
the procedure does not control sclerosing cholangitis.
For advanced disease with liver failure, the treatment
of choice is liver transplantation. The 1- and 2-year actuarial survival rates are over 88%.
8
The recurrence rate of
primary sclerosing cholangitis is low. An interesting question, for which a definitive answer does not exist, is
whether post-transplantation immunotherapy increases
the incidence of carcinoma in patients who have associated ulcerative colitis. It is probably prudent to perform
total proctocolectomy in patients with a history of ulcerative colitis of 15 years or longer.
TABLE 7.11. Classification by Strasberg and colleagues of
Laparoscopic Injury Biliary Tract
Type A: Bile leak from minor bile ducts in continuity with
common bile duct
䊏
Cystic duct leaks
䊏
Leaks from liver bed (ducts of Luschka)
Type B: Occlusion of part of the biliary tract
䊏
Occlusion of aberrant right hepatic duct
Type C: Bile leak from duct not in communication with common
bile duct
䊏
Transection of aberrant right hepatic duct
Type D: Lateral injury to extrahepatic bile ducts
䊏
May involve common hepatic duct, right or left hepatic duct
Type E: Circumferential injury of major bile ducts
䊏
E1: Excision of common hepatic duct <2cm
䊏
E2: Excision of common hepatic duct >2cm
䊏
E3: Total excision of common hepatic duct
䊏
E4: Excision of common hepatic duct and left and right hepatic
ducts
䊏
E5: Combined common hepatic duct and aberrant right hepatic
duct injury
Source: Reprinted with permission from Strasberg SM, Hertl M, Soper NJ.
An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–125.
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