Initial management of suspected biliary injury after laparoscopic cholecystectomy

Figure 1 Classification of the bile duct injuries after cholecystectomy. A: Schematic classification of bile duct injuries in laparoscopic cholecystectomy. Originally developed by Strasberg et al in 1995[7]. A bile leak from the cystic duct stump or minor biliary radical in the gallbladder fossa; B: Occluded right posterior sectoral duct; C: Bile leak from the divided right posterior sectoral duct; D: Bile leak from the main bile duct without major tissue loss; E1: Transected main bile duct with a stricture more than 2 cm from the hilus; E2: Transected main bile duct with a stricture less than 2 cm from the hilus; E3: Stricture of the hilus with right and left ducts in communication; E4: Stricture of the hilus with separation of right and left ducts; E5: Stricture of the main bile duct and the right posterior sectoral duct; E6: complete excision of the extrahepatic ducts involving the confluence (this injury is not described in Strasberg’s original classification). Citation: Connor S, Garden OJ. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 2006; 93(2): 158-168. Copyright ©John Wiley & Son´s Ltd 2006. Published by John Wiley & Son´s Ltd[8].

Figure 2 Initial diagnostic flowchart in suspected complication after laparoscopic cholecystectomy. Any patient not recovering correctly in the immediate post-operative phase should be referred and evaluated for the possibility of a complication. Early consultation with the hepato-biliary unit is recommended when bile duct injury or other severe complication of laparoscopic cholecystectomy is suspected. CT: Computed tomography; MRI: Magnetic resonance imaging; MRCP: Magnetic resonance cholangio-pancreatography. (Primovist: Bayer AG, Leverkusen, Germany).

Figure 3 Flow chart of containment and initial treatment in bile leak or bile duct injury. Reconstructive surgery should be planned and performed by hepato-biliary specialists only. ICU: Intensive care unit; CT: Computed tomography; MRI: Magnetic resonance imaging; MRCP: Magnetic resonance cholangio-pancreatography; ERC: Endoscopic retrograde cholangiography; PTC: Percutaneous transhepatic cholangiography catheter drainage; FCSEMS: Fully covered self-expandable metal stent.