Ch. 54 – Biliary System

1570 Section X Abdomen
Partial injury
(30%) to CBD
Cautery injury
Intraoperative
cholangiogram
Roux-en-Y
choledochojejunostomy
strictures. Unrecognized injury to the hepatic artery or a
portal vein branch occurs with a frequency of 12% to
47% concomitant with a bile duct injury. Certainly, if
signifi cant bleeding required urgent control at the time
of the original operation, a vascular injury should
be considered. However, the clinical consequences of
hepatic artery injury are not fully known, but at least one
study suggested that the presence of a right hepatic artery
disruption should not affect the surgical repair of a bile
duct injury. 30,31 In patients presenting with late strictures
with evidence of liver dysfunction, a CT arteriogram
should be performed to evaluate for evidence of portal
hypertension.
Intraoperative Considerations
The management of postoperative biliary strictures following
ductal injury depends on the degree of injury, the
presence of stricture-induced complications, and the
operative risk of the patient. After recognition of a bile
duct injury or stricture, a multidisciplinary team consisting
of experienced interventional radiologists, endoscopists,
and surgeons, coordinated by an experienced hepatobiliary
surgeon, should plan the following specifi c goals:
1. Control the infection (abscess or cholangitis)
2. Drain the biloma
3. Complete the cholangiography
4. Provide defi nitive therapy with controlled reconstruction
or stenting (Fig. 54-22)
These goals do not mandate elaborate workup and
delayed repair in all cases. Initial experience suggested
that immediate repair of bile duct injury from cholecystectomy
can give good results with low morbidity when
performed properly; more recent data, however, suggest
Complete transection
of CBD
>3 mm
in size
Injury to isolated
hepatic duct
Reimplantation or
reconstruct with Roux-en-Y
hepaticojejunostomy