Bile duct injuries are the most serious complication associated with cholecystectomy. The incidence of biliary injury has increased substantially in the era of laparoscopic cholecystectomy. Currently, data from large surveys of patients undergoing laparoscopic cholecystectomy suggest an incidence of 0.4% to 0.6%. Management of these injuries requires a multidisciplinary approach involving interventional radiology and endoscopy combined with experienced hepatobiliary surgeons. Although mortality is uncommon, these injuries remain a major source of patient morbidity and major hospital costs and negativity affect patients’ short-term quality of life.

Less than one-third of iatrogenic bile duct injuries are actually detected at the time of the cholecystectomy. The majority are therefore identified postoperatively, and in general, present in one of two forms: biliary leak with biloma formation or complete biliary obstruction. Most commonly, the hepatic duct has been transected and incompletely clipped resulting in bile leakage into the peritoneal cavity. These patients usually present 24 to 72 hours after cholecystectomy with increasing abdominal pain, distension, nausea, and evidence of early sepsis. Patients in whom the common hepatic duct has been completely clipped will present days to weeks after cholecystectomy with pain and jaundice, or less commonly pain and fever indicative of cholangitis. Any such atypical course from the routine recovery for a laparoscopic cholecystectomy should prompt an immediate evaluation for possible biliary injury.

The precise indications and contraindications for operative therapy of a bile duct injury/stricture are based on (1) the mode of injury, (2) the interval between the injury and its diagnosis, (3) the clinical condition of the patient, and (4) the local conditions inherent within the operative field.

The general strategy for managing the injury however involves avoiding immediate operative intervention to attempt definitive repair. If early laparotomy is performed in the face of sepsis continued uncontrolled bile leak or following complete transection of the common bile duct, marked inflammation in the operative field will obscure the area and make identification of the biliary system difficult. Biliary reconstruction under these circumstances is therefore a relative contraindication because it will be technically challenging and frequently end in long-term failure in the form of an anastomotic leak or biliary stricture. To avoid this outcome, early management involves less invasive measures to first define the anatomy of the injury, and then to control biliary sepsis or the ongoing bile leak. Definitive repair is carefully planned and undertaken weeks following the initial injury, well after periportal inflammation has been allowed to resolve. Delaying definitive repair also has the substantial advantage of allowing the clinician time to investigate for concurrent hepatic arterial vascular injury using arterial phase computed tomography (CTA). If there has been a concurrent arterial injury however, a delay will also allow the delineation of both the zone and level of ischemia. Early bile duct repair in the setting of an unrecognized hepatic arterial injury leads to a significantly higher stricture rate.

In cases in which the injury is actually recognized at the time of the cholecystectomy, an attempt at immediate repair is often warranted. The first step in this repair is an intraoperative cholangiogram, which will confirm and better define the injury and will help determine the most appropriate surgical management. If a small segmental duct (<3 mm in diameter) has been injured and cholangiography demonstrates segmental or subsegmental drainage by the injured system, simple ligation of the injured duct will be adequate treatment. If the injured duct is larger (4 mm in diameter) or provides sectoral or lobar drainage as demonstrated by the cholangiogram, surgical repair is required. If the injured segment of the bile duct is short (<1 cm) and two resultant viable ends can be opposed without tension, an end-to-end primary anastomosis is a reasonable strategy, recognizing, however, that late stricture rates are not insignificant. In this case, a generous Kocher maneuver will mobilize the duodenum out of the retroperitoneum and alleviate tension at the repair. The injured ends of the bile duct are debrided to healthy mucosa and a spatulated end-to-end repair is made using interrupted 5-0 monofilament absorbable suture. A T-tube should be placed below and not through the anastomosis (Fig. 17.1). For proximal injuries near the hepatic duct bifurcation or if the injured segment of the bile duct is longer than 1 cm, an end-to-end primary biliary anastomosis will result in excessive tension and should always be avoided in favor of a Roux-en-Y reconstruction.
Finally, if the circumstances of the procedure or the experience of the surgeon are such that an optimal repair is not possible, adequate drainage and transfer to a tertiary care biliary surgeon is advised.