12th edition - starters package in laparoscopy ircad/eits

12th Edition - Starters Package in LaparoscopyIRCAD/EITS Strasbourg (France) – October 20+21, 2011.

Teacher : Dr. Benoît Navez – UCL Saint-Luc Bruxelles

Bile duct injuries. 1

Bile Duct Injury during cholecystectomy

Catherine HUBERTJean-François GIGOTBenoît NAVEZ Division of Hepato-Biliary-Pancreatic Surgery

Department of Abdominal Surgery and Transplantation

Strasbourg, IRCAD, October 2010

« No surgeon is immunefrom the risk of bile duct

injury, and no case is simply routine »

B.J. Caroll, Surg Endosc 1998, 12, 310-314




TOPICS

Bile Duct Injury during Lap Chole

1. Prevalence, mechanisms, prevention and diagnosis

2. Treatment strategies:a. primary surgical repairb. postoperative biliary fistulac. biliary peritonitisd. biliary stricture

• Bile duct injury: 0.4 – 0.6 % (extrahepatic bile duct)

• Biliary Leaks: 0.5 – 1 % (Accessory bile ducts:

cystic duct, Luschka duct)

Delaitre et al. 6512 pt - 1992 (France)Wayand et al. 7351 pt - 1993 (Austria)Solheim et al. 2612 pt - 1995 (Norway)Go et al. 6076 pt - 1993 (Netherlands)Croce et al. 6865 pt - 1994 (Italy)

Deziel et al. 77604 pt - 1993 (USA)Bernard et al. 13159 pt - 1993 (USA)Cocks et al. 6000 pt - 1993 (Australia)Windsor et al. 4000 pt - 1994 (New Zealand)Kimura et al. 1989 pt - 1993 (Japan)

EUROPEAN NATIONAL SURVEYS

POSTCHOLECYSTECTOMY BILE DUCT LEAKAGE




Multicenter Belgian Surveys

Vereecken 1992 3244 LC all type 0.50 %

Gigot < 1997 9959 LC all type 0.50 %

Vandesande 1997 10.595 LC all type 0.37 %

11.628 all type all type 0.58 %

Vandesande 2000 14.715 LC all type 0.31 %

16.915 all type all type 0.54 %

Navez 2004 1089 LC acute cholecystitis 1.2 %

Authors Period Patients type of clinical BDI rateprocedure presentation

X 2.5

Incidence

RISK FACTORS for BDI during LC

1. factors inherent to the laparoscopic approach2. inadequate training of the surgeon3. local risk factors (cholecystitis)4. inappropriate surgical technique5. lack of IOC performance6. lack of adequate conversion

in difficult cases

technicalrisk factors

B NAVEZ - JF GIGOT




loss of depth perceptionloss of manual palpation surgeon's dependance to the equipment limited field easily obscured by bile or

blood (loss of vision)Oblique and tangential view

1.RISK FACTORS INHERENT TO THE LAPAROSCOPIC APPROACH

0

5

10

15

20

25

50 100 150 200 250 300 350 400 450

Nb ofBDI

!GIGOT, Surg Endosc 1997, 11 : 1171-1178

absent present

< 50 cases : 55 % 45 %

> 50 cases : 24 % 76 %

SURGEON EXPERIENCE and LOCAL RISK FACTORS *

Surgeon’s experience (Nb of LC)

• anonymous survey on 9959 LC• 65 patients with BDI (0.5 %)

p = 0.03




misidentification of cystic duct : the « classical » injury

‐with CBD duct during IOC 6 %during dissection 35 % 43 %

‐with cystic artery 1.5 %

Laparoscopic belgian survey

cystic duct avulsion

CBD tenting

Clipping during urgent haemostasis

B NAVEZ - JF GIGOT




DIFFICULT 3. LOCAL RISK FACTORSAND BILE DUCT INJURIES

acute or severe chronic inflammation !!! (65 %)

large impacted stone in the Hartman pouch (16 %)

MIRIZZI syndrome +/- bilio-biliary fistula (4%)

Morbid obesity

Anatomical anomalies

complete cholangiogram!

You can perform a Subtotal cholecystectomy

leave a piece of gallbladder wall on the Calot triangle and at the level of the Hartman Pouch

In SEVERE CHOLECYSTITIS with anomalous RHD




Variations of Cystic Duct

Variations of Cystic Artery




Dangerous anatomy

Dangerous anatomy




Dangerous gallbladder

disease

During yourfirst 100 LC ,

select « easy » cases

!!!




1. Recognition of Duct transsection during dissection

2. Unexplained bile in the operating field

3. When conversion for hemostasis (arterial injury)

4. Intra‐Operative Cholangiogram• Contrast extravasation• No opacification of Common Hepatic Duct• Incomplete Intra‐hepatic ducts

Intra‐Operative Cholangiogram (I.O.C.)

Detection of BTI at 2 conditions

Must be performed at the end of the dissection

Good interpretation by the surgeon

(23 % of misinterpretation in Belgian series)




A completed and correctly interpreted IOC

1. increases the chance of detection

2. decreases the severity of injury

3. decreases the related mortality and morbidity

* lateral injury : 48%

* completetranssection : 32%

* resection : 10%* thermal : 11%

SEVERITY SITE ( BISMUTH classif. )

* type I : 51%* type II : 28%

* type III : 9%* type IV : 3%* type V : 9%

52% 21%

GIGOT, Surg Endosc 1997; 11: 1171

BDI during LC




CLINICAL PRESENTATION

• peroperative detection (29) :

• external biliary leak (8): 12%• biliary peritonitis :

- localized (biloma) (3): 6%- diffuse (19) : 29 % !!!

• biliary stricture :- early (3): 4.5%- late (3) : 4.5%

65 patientsBDI during LC : the Belgian Registry

51 %

44.5 %

Bile Duct Injury during Lap Chole

* the best : to avoid injury

* the best when BDI occurs :to diagnose immediately the injuryand to repair properly

* the worst : to diagnose lateto try to repair in difficult conditions

Failure to recognize a BDI - increases patient morbidity from delayed diagnosis- makes further repair more difficult.




* IMMEDIATE REPAIR : * small caliber of non dilated ducts(during the 1st op) * but absence of local inflammation

* EARLY REPAIR : * non dilated ducts !!!(<2months) * local inflammation

* sepsis and poor patients condition

* LATE REPAIR : * optimized conditions(>2-3 months) * presence of ductal dilatation with fibrotic tissues

Bile Duct Injury during Lap.Chole.TIMING of REPAIR

1.Early REPAIR of BDI

THERMAL INJURY In 1/3 of BDI VASCULAR INJURY

risk factors for late stricture

30-50%type IV : 60 %

Stewart et al. Ann Surg 2003; 237: 460

Patients Mortality Biliary Reinterv. FU (mo) Recurrentcomplic. median Stricture

. Perop. detect. : 7 % 24 % 14 % 46

. Peritonitis : 50 % 23 % 5345 %

34 %

20 %

29 %

47 %




Laparoscopic cholecystectomy= minimally invasive procedure

BDI = maximally invasive situation→ change your philosophy→ treat properly→ medico‐legal consequences

PHILOSOPHY of TREATMENT

B. POST- OPERATIVE BILIARY PERITONITIS

High suspicion for BDI should be maintained for any patient who do not recover normally and quickly after LC.

The mean delay for reoperation in the Belgianregistry was … 11 days (1 – 21)

!




Bile Duct Injury during Lap.Chole.

MANAGEMENT of BILE DUCT INJURY DIAGNOSED EARLYafter LAPAROSCOPIC CHOLECYSTECTOMY

• external biliary fistula• bile peritonitis• obstructive jaundice from biliary stricture

3 types of postoperative clinical presentations :

A. Postoperative Biliary Fistula

RADIOLOGICAL EVALUATION

AVOID to REOPERATE … before complete evaluationPURPOSE

1. to define site and severity of BDI

2. to evaluate the intraabdominal bile leakage

3. to detect coexistent injury

TYPE of IMAGING STUDIES

1. CT with contrast injection is superior to US

2. MRI is a “all-in” exam (cholangio + angio-MRI) to define lesions

3. ERCP is the most useful tool in partial injury

(excepted if complete obstruction or transsection)




WAIT

ERCP

CT or (MRI)

diffuse bileperitonitis

localizedbiloma

* no collection* good clinical condition

if - persistant > 1 week or worsening

- LFTs elevated (obstruction ?)

- total biliary diversion

SURGERY Percut.RX drainage

- amount of bile / 24 h.

- evolution of biliary leak

to define ‐ type / site / severity

cystic, Luchka * partial injury * complete transsection

ducts * lateral clippin * resection

ERCP

ES + prosthesis ES + prosthesisor

surgery

Efficient endoscopic management

SURGERY

ENDOSCOPIC MANAGEMENT




MANAGEMENT of BILIARY PERITONITIS

LAPAROTOMY

• clinical improvement• no residual bile collections

on repeat CT examination

* peritoneal lavage

* biliary drainage- bilio- digestive anastomosis

…. if possible- otherwise, external diversion

* septic condition ( infected bile)* long standing peritonitis

* good clinical condition* recent peritonitis

partial laceration,cystic or Luchka duct

completelaceration

1. endoprosthesis2. percutaneous or

surgical drainage(lap or open)

EMERGENCY TREATMENT

ERCP

suture suture+ T tube HJA . excise and HJA+ T‐tube HJA . diversion

- type- severity

classification of injuryby IOC

partialinjury

completetranssection

wideresection

thermalnecrosis




Repair of a lateral injuryResection of necrotic margins

Transversal suture

T‐Tube introduced at distance of the suture

End to end choledoco‐choledocostomy+ T‐Tube (complete CBD transsection)Good vascularisation of bile duct stumps

Tension‐free Suture (absorbable 5/0)

T‐Tube introduced at distance of the anastomosis

B NAVEZ - JF GIGOT

END-to-END BILIARY REPAIR

CAUSES of FAILURES

* loss of ductal tissue

* tension on the suture line

* inadequate blood supply

(thermal injury)

* small caliber of the ducts

* proximal location of BDI




STRATEGY OF TREATMENT

do a selective cholangiography !!

if limited biliary sector(1 segment)

if large biliary sectorand large stoma

if large biliary sectorand thin duct

then, close it permanently

make a repair (suture + Tube orHJA)

clip temporary and comeback later, when dilated

BDI due to an ANOMALOUS R. HEPATIC DUCTBDI due to an ANOMALOUS R. HEPATIC DUCT

lateral BDI to anomalous RHD

during delayed LC for severe cholecystitis

primary repairby suture with T-tube insertion

BDI due to an ANOMALOUS R. HEPATIC DUCT




TOTAL BILIARY DIVERSION

INDICATIONS

• when a biliary repair is impossible or unsafe- proximal thermal necrosis- severe inflammation- tiny proximal duct

TECHNIQUE• drain into the proximal biliary stump• multiples large sub-hepatic drains

…. NOT too close of the hepatoduodenalligament …. risk of vascular injury !

• (large sub-hepatic omentoplasty)

Day 3 : 2nd look Laparoscopy • I.O.C.• Lavage

• External biliarydrainage

• BTIBismuth type IV

B NAVEZ - JF GIGOT




Hepatico-jejunal anastomosis:The HEPP-COUINAUD APPROACH

Hepatico-jejunal anastomosis:The HEPP-COUINAUD APPROACH

« mucosa-to-mucosa » hepatico-jejunostomy




HEPATIC RESECTIONBDI + Vascular injury

Major RHD injury + severe atrophy/sepsis right liver(vascular injury or prolonged biliary obstruction)

LIVER TRANSPLANTATION

BDI + Vascular injury

▪ Acute liver failure

▪ Biliary cirrhosis

Long-term follow-up (at least 10 years) is mandatorybefore definitive conclusions about the outcome of BDI.

BILE DUCT INJURY during LAP. CHOLE

Female , 74y1994: ‐ type IV BDI post lap chole

Hepp‐Couinaud HJAFU once a year in outpatient clinic(biology and cholangioMRI)

Completely asymptomatic with normal follow‐up untill june 2009April and June 2009: Cholangitis Normal LFT (after cholangitis)MRI: ! Stenosis at the level of the LHD




CLINICAL CASES

Clinical case : 1

CT SCAN

Female, 35y

D1: abdominal pain

CRP: 22WBC: 24000Normal LFT

ERCP




WHAT SHOULD YOU DO?

1.Wait and see

2.Percutaneous drain alone

3.Endoprothesis alone

4.Percutaneous drain and endoprothesis

5.Open Hepatico-jejunostomy and peritoneal lavage

Clinical case : 1

Answer:

4.Endoprothesis and percutaneousdrain




Clinical case 2

* F 30 years-old* Lap chole

9 days ago

Bile peritonitis

Sepsis++ERCP

1.Wait and see

2. Endoprothesis and percutaneous drain

3.Surgical exploration




Answer: 3. Surgical exploration

D9: Surgical exploration:excision of EHBD and main biliary convergenceDiffuse Biliary peritonitis

1. Peritoneal lavage and direct end to end suture

2. Peritoneal lavage and suture with T-tube insertion

3. Peritoneal lavage and hepatico-jejunal anastomosis

4.Peritoneal lavage and external biliary diversion




Clinical case : 2

Answer:

4.Peritoneal lavage and external biliary diversion

12th edition - starters package in laparoscopy ircad/eits

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