Biliary Injury in Lap Chole - TAddona

Biliary Injury in Lap Chole - TAddona - Biliary Injury...

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Unformatted text preview: Biliary Injury & Biliary Injury & Laparoscopic Cholecystectomy Causes of Biliary Injury in LC Causes of Biliary Injury in LC Failure to properly occl. the cystic duct Injury to the ducts in the liver bed caused by entering a plane too deep to the gallbladder Cautery Misuse – thermal necrosisductal tissue loss Pulling forcefully up on the gallbladder when clipping the cystic duct tenting injury to the junction of the CBD & common hepatic duct Biliary Injuries During Cholecystectomy (CCY) Reviews revealed the incidence of biliary injury during open CCY to be 0.1­0.3% 1995 – Strasberg’s study which incl. more than 124,000 laparoscopic cholecystectomies (LC) reported in the literature found the incidence of major bile duct injury to be 0.5%. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995 Jan; 180 (1) : 101­25. Strasberg & Soper classificaiton Strasberg & Soper classificaiton of bile duct injuries Type A – bile leak from minor duct still in continuity w/ the CBD…cystic duct or liver bed Type B – occlusion of part of the biliary tree; ex. Result of an injury to an aberrant right hepatic duct. Type C – leak from duct NOT in communication w/ CBD Type D – lateral injury to extra­ hepatic bile duct Type E – circumferential injury The Effect of Acute Cholecystitis The Effect of Acute Cholecystitis on Biliary Injury The incidence of bile leakage after emergency LC for acute cholecystitis is higher than that for elective. 1.37% in acute chole v. 0.09% in elective n = 3300 (10yrs); retrospective (Taipei) Lien et al. Management of bile leakage after LC based on etiologic classification. Surg Today (2004) 34:326–330 Diagnosis of Bile Leaks Diagnosis of Bile Leaks Persistent fullness, anorexia, abdominal pain, fever & tenderness,jaundice, elev WBC High level of suspicion following surgery Bile draining from a drain left in the operative field Radiographic Diagnosis of Radiographic Diagnosis of Biliary Injury US/CT – detect bilomas (poss. perc drainage) Radiographic Diagnosis of Radiographic Diagnosis of Biliary Injury US/CT – detect bilomas (poss. perc drainage) HIDA – presence of active bile leak (physiologic) Radiographic Diagnosis of Radiographic Diagnosis of Biliary Injury US/CT – detect bilomas (poss. perc drainage) HIDA – presence of active bile leak (physiologic) MRCP – demonstrate dilated/stenotic biliary tract; retained stones…..not physiologic nor therapeutic ERCP ERCP Provides exact anatomical diagnosis of bile duct leak; while allowing treatment w/ decompression of the biliary tree. Principal of treatment is to establish a pressure gradient that will favor flow into the duodenum not the leak site; may entail removal of retained stone or internal stenting +/­ sphincterotomy Internal stenting is currently the procedure of choice for treating bile duct leaks ( types A & D) Cessation of bile extravasation in 70­95% of cases w/in 7 days Percutaneous Transhepatic Percutaneous Transhepatic Cholangiography Another method of non­surgical mgmt of bile leak Usually reserved for when ERCP unsuccessful; since bile ducts of normal caliber increasing the difficulty of the procedure Plastic surgery meets GI surgery Plastic surgery meets GI surgery BOTOX injection to sphincter of Oddi Operative Management Operative Management Timing of diagnosis Surgeon skill Intraoperative Injury Intraoperative Injury Strasberg D injury ­ (partial injury to a major duct) should be repaired at initial operation w/ T­tube drainage Strasberg E injury ­ (complete transection of major duct) may be reconstructed at the initial operation w/ a R­Y hepaticojejunostomy. *** No primary re­anastomosis secondary to ischemic factors*** Detection in post­op period Detection in post­op period Abx, nutrition support, percutaneous drainage of bile collex (US or CT) MRCP, PTC or ERCP to delineate location of injury. Once sepsis and leaks are controlled, then may perform definitive reconstruction w/ R­Y hepaticojejunostomy Kaman et al. Management of Major Bile Duct Injuries following LC. Surg Endosc (2004)18:1196 –1199 ...
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