laparoscopic cholecystectomy - PowerPoint Presentation

1. laparoscopic cholecystectomy (LC)- related bile duct injuries.Emad Hamdy Gad,MDAssociate professor of surgery, NLI, Menoufiya University, EgyptConsultant of surgery, Bilgorashi hospital, Baha, KSA

2. Introduction

3. - Despite increased surgical skills and experience regarding LC, the rate of LC related BDI(leak±stricture±vascular injury), is still higher in comparison to open cholecystectomy (0.2%-0.8% vs. 0.1-0.2% respectively) Cuendis-Vela´zquez et al,2016, Hogan et al, 2016. Fong et al, 2018- There are several risk factors for the occurrence of these injuries(I.e. Surgeon inexperience, misinterpretation of biliary anatomy,poor visualization of the surgical field, inflammation, Mirrizi's syndrome, excessive fibrosis in Calot's triangle, adhesions, hemorrhage and lack of intra-operative cholangiogram (IOC)??.Most significant injury occurs when surgeon misidentifies CBD as cystic duct and cuts this structure.97% of injuries due to visual perceptual illusion, and only 3% of injuries due to faults in technical skill.

4. LC related BDIs range from minor injuries to complex hilar injuries as classified by Strasberg et al; where the major types corresponds to type E injuries including ongoing stricture, complete occlusion, resection or division of the bile ducts Sahajpal et al, 2010, Meek et al, 2018. The mechanisms of these injuries involve thermal injuries, scissors, ligatures or clips. These injuries are dangerous with significant morbidity, and mortality. Moreover, failure or delay in the early recognition or referral, or in-appropriate management of them lead to catastrophic consequences (biliary peritonitis & sepsis, cholangitis, portal hypertension & secondary biliary cirrhosis, and liver failure. Costamagna et al, 2015, Tropea et al, 2016, Martinez-Lopez et al, 2017.

5. Surgical biliary enteric reconstruction including the Hepp-Couinaud approach, at a specialist hepatobiliary center by an experienced surgeon is the most effective treatment of these injuries with perfect long-term results Sulpice et al, 2014, Pekolj et al, 2015, Martinez-Lopez et al, 2017, Booij et al, 2018However, end-to-end biliary anastomosis can be utilized as a treatment strategy if BDI is detected during surgery, with no extensive tissue loss, or inflammation. Nevertheless, symptomatic patients with associated vascular lesions, lobar parenchyma atrophy, or abscesses benefit from hepatectomy Li et al, 2012, Booij et al, 2018

6. Classification- location of injury - mechanism & type of injury- effect on biliary continuity- timing of identification- Each plays significant role in determining appropriate management & operative repair

7. - Bismuth classification (1982)era of Open Cholelocation of biliary strictures with respect to hepatic bifurcation degree of injury correlates with surgical outcomes

8. TypeCriteriaALeak from Cystic duct or small ducts in liver bedBOcclusion of an aberrant RHDCTransection without ligation of an aberrant RHDDLateral injury to a major bile ductE1Transection >2 cm from the hilumE2Transection <2 cm from the hilumE3Transection in the hilumE4Separation of major ducts in the hilumE5Type C injury plus injury in the hilumStrasberg Classification

9. Strasberg Classification

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13. Mechanism of Common Bile Duct Injury (Stewart-WayClassification)CBD mistaken for cystic duct but recognizedincision in cystic duct extended into CBDClass ILateral damage to the CHD from cautery or clips placed on ductClass IICBD mistaken for cystic duct, not recognizedCBD, CHD, R, L. hepatic ducts transected and/or resectedClass IIIRHD mistaken for cystic duct, RHA mistaken for cystic artery,RHD and RHA transectedClass IV

14. Classical” laparoscopic injuryCBD mistaken for cystic ductCBD clipped & resectedProximal dissection & division  injury to RHA

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16. Bile leak related to LC- Definitions and classifications:- The ISGLS defines a post LC biliary leak as a bilirubin concentration in the drain fluid at least three-times the serum bilirubin concentration on or after postoperative day 3.- Grading system of bile leak according to ISGLS:Change in clinical managementGradeNo or minimalARadiographic or endoscopic intervention or Grade A for > 1 weekBOperative interventionC

17. Controlled and Uncontrolled Biliary Leaks and fistula: Partial or complete duct devision:Minor or major leak:Low output drainage or high output drainage:- Leak site : The cystic duct stump, ducts of Luschka, other ducts in the gallbladder fossa, and major extrahepatic bile ducts including aberrant sectorial ducts comprise the potential sites of biliary leakage. - The cystic duct stump represents the most common site of leak and reported risk factors include emergency surgery, incomplete or disrupted closure of the cystic duct, width and degree of inflammation of the cystic duct, and presence of common bile duct stones

18. Diagnosis and identification of LC related bile leak and injury

19. Timing of IdentificationIntra-op: Post-op:1st 3 days:After 3 days: After 6 weeks:

20. Intra-operative recognition:bile leak into field from lacerated or transected duct or injury identified by IOC.About 30% BDI recognized at time of initial surgeryRepair at the index procedure should be undertaken only if experience and expertise are available. Otherwise, patients should be referred appropriately.So: Drain and refer to HPB center OR manage according to injury type after doing IOC: A: Clipping or suture ligation B: HJ C: HJ D: primary repair ± T-tube E: End to end anastomosis over T-tube or HJ

21. IOC shows complete closure of CHD

22. Post operative recognitionclinical presentation - Obstruction Clip ligation or resection of CBD  obstructive jaundice, cholangitis - Bile Leak - The diagnosis of a biliary leak is generally straightforward if an operative drain was placed and it communicates with the site of bile leakage. In general, inspection of the effluent is confirmatory of a biliary leak. If diagnostic uncertainty exists, analysis of bilirubin concentration is performed. - More commonly, localized biloma or free bile ascites / peritonitis, if no drain - If a drain was not placed or does not communicate with the site of leakage, patients may present with signs of systemic inflammatory response (fever, tachycardia, tachypnea, leukocytosis), localized abdominal pain, expression of bilious fluid from the incision and port sites, or more subtle findings such as delayed gastric emptying or ileus

23. Post operative hepatic biloma

24. Investigations

25. - Ultrasound & CT scan intraabdominal collections, bilomas or ascites, if bile leak dilatation of biliary tree, if bile duct obstruction - MRCP: Noninvasive May avoid invasive procedures like ERCP or PTC - ERCP and PTC: Diagnostic and therapeuticsFistulogram/sinogram - HIDA scan - CT angiography

26. MRCP shows cystic duct leak

27. MRCP shows E1 injury

28. ERCP shows complete clippingof CBD

29. PTC shows complete closure of CHD

30. Prevention1- cystic duct stump leaks: The cystic duct stump should be appropriately identified and secured by A variety of methods like titanium clips, locking clips, harmonic scalpel, suture ligature, endo-loops and endovascular stapling devices. The cystic duct wall must be vascularized and free of significant inflammation. For a wide cystic duct, additional clips, ligature, endo-loops or an endovascular stapler may be used after confirming the anatomy. Gentle traction should be used to avoid avulsion of the cystic duct from the common hepatic duct. 2- Leakage from ducts of Luschka or from the fossa is likely related to dissection into the liver parenchyma. Efforts to stay in the correct plane and ligation of accessory ducts entering the gallbladder from the fossa decrease them.

31. 3- preventing major biliary injuries by: - 30° laparoscope, high quality imaging equipment - Firm cephalic traction on fundus & lateral traction on infundibulum, so cystic duct perpendicular to CBD - Dissect infundibulo-cystic junction - Expose “Critical view of safety” before dividing cystic duct - Convert to open, if unable to mobilise infundibulum or bleeding or inflammation in Calot’s triangle - Routine intra-op cholangiogram(controversy), when to do it? - “Fundus-first” dissection

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34. Critical view of safetyCalot’s triangle dissected free of all tissue except cystic duct & arteryBase of liver bed exposedWhen this view is achieved, the two structures entering GB can only be cystic duct & arteryNot necessary to see CBD

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36. ManagementKey roles:1- Role of IOC in prevention of injuries? When to use?2- The underlying principles for the management of a biliary leak are to achieve source control with adequate drainage(US/CT guided or surgically), control of the intra-abdominal sepsis, determine the anatomy of the leak to guide further treatment, and assess for distal obstruction and, when appropriate, definitive repair. ( NB. Many biliary leaks resolve with conservative measures.) 3- According to strasberg classification: The simpler injuries, such as types A and D, may be treated at the index procedure when discovered intra-operatively, or by endoscopic or percutaneous techniques when they present in the postoperative period. Some injuries, such as E1 and E2 injuries, and occasionally more complex injuries, may be treated by nonsurgical techniques when they present as strictures. B and C injuries and most E injuries require surgical reconstruction.

37. 4- Multidisciplinary staff meeting:including surgeons, endoscopists, radiologists, and anaesthetists for controlling initial patient condition must occur where different intervention procedures are decided before the definitive operation (I.e.laparotomy, endoscopic and/or radiologic ones); the laparotomy included drainage of biliary collection ± external biliary diversion, where the endoscopy included ERCP ± sphinectrotomy ± dilatation ± stenting and lastly, the radiology included percutaneous pigtail drainge ± PTD.5- A detailed preoperative evaluation by(Laboratory(I.e. LFT,…), and imaging(US, CT, MRCP, ERCP, PTC, fistulogram,….), improving of patient general condition before the definitive procedure by co-operation of surgeons, endoscopists and intervention radiologists, correction of nutritional, fluid-electrolyte and acid base disorders, giving octreotides and controlling sepsis; and then finally performing meticulous wide anastomosis by experienced surgeons in specialized hepato-biliary units are required for achieving long-term success after repair of MBDIs. 6-No rush to proceed with definitive management of BDI as delay of several weeks)(<6weeks) allows local inflammation to resolve & almost certainly improves final outcome.

38. Definitive managementGoal re-establishment of bile flow into proximal GIT in a manner that prevents cholangitis, sludge or stone formation, re-stricturing & progressive liver injuryBile duct intact & simply narrowed  Endoscopic dilatation(ERCP) or percutaneous(PTD).Operative Management: Indications for operative exploration in the setting of biliary leaks or fistula include (1) inability to achieve adequate source control by endoscopic or percutaneous approaches, (2) generalized peritonitis, (3) biliary leaks associated with complete division of the common hepatic duct or common bile duct, and (4) biliary leaks from an excluded segment.

39. Lateral duct wall injury or cystic duct leak  transampullary stent controls leak & provides definitive treatmentDistal CBD must be intact to augment internal drainage with endoscopic stent

40. CBD transection  normal-sized distal CBD upto site of transectionPercutaneous transhepatic cholangiography (PTC) necessarySurgery

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42. Biliary enteric anastomosisMost laparoscopic BDI – complete discontinuity of biliary tree Surgical reconstruction, Roux-en-Y hepaticojejunostomytension-free, mucosa-to-mucosa anastomosis with healthy, nonischemic bile duct

43. Figure (1): A, B: MRCP and CT showing type E1 BI, C, D: RY HJ without stentE.H. Gad EH, et al, 2018 ABCD

44. Figure (2): A, Fistulogram showing type E3 BI, B, C: patient underwent HJ with stent Gad EH, et al, 2018 ABC

45. Figure (3): A- MRCP showing Type E3 biliary stricture, B,C: HJ without stent steps. Gad EH, et al, 2018 ABC

46. Figure (4): A: MRCP showing BI typeE3, B,C, HJ with stent .Gad EH, et al, 2018 ABC

47. Figure (5): MRCP showing type E4 injury with RT lobe atrophy underwent RT hepatectomy with biliary reconstruction Gad EH, et al, 2018

48. Figure (6): A,B,C,D: MRCP,MRI,CT and CT angiography respectively showing BI type E4 with RT HA and PV injuries and multiple hepatic abscesses in RT lobe, this patient underwent RT hepatectomy with biliary reconstruction. Gad EH, et al, 2018 ABCD

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50. Treatment summaryStrasberg Type A :conservative + PD or ERCP + sphincterotomy + stent + PD Type B & C:HJType D – primary repair + T-tube (if no evidence of significant ischemia or cautery damage at site of injury) More extensive type D & E injuries – Roux an-Y HJ + stent or end to end anastomosis with T-tube or internal stent

51. Thank you