How to manage a complete transection of the Common Bile Duct (CBD) just above the duodenum during laparoscopic cholecystectomy?

Management of Complete Common Bile Duct Transection During Laparoscopic Cholecystectomy

Hepaticojejunostomy (Roux-en-Y reconstruction) is the recommended treatment of choice for complete transection of the common bile duct (CBD) just above the duodenum during laparoscopic cholecystectomy. 1

Classification and Assessment

Complete transection of the CBD represents a major bile duct injury (BDI), classified as Strasberg type E in the commonly used classification system. This type of injury is associated with tissue loss and requires complex reconstruction for definitive management.

When such an injury occurs intraoperatively, proper documentation is essential:

• Location of injury (in this case, CBD just above the duodenum)
• Complete vs partial transection (in this case, complete)
• Presence of associated vascular injury
• Amount of tissue loss

Management Algorithm

1. Immediate Steps

• Control bile spillage
• Obtain surgical consultation from hepatobiliary (HPB) specialist if available
• Consider referral to an HPB center if adequate expertise is not available locally 1

2. Definitive Management

• Hepaticojejunostomy is the treatment of choice for this major BDI with complete transection 1
• The procedure involves:
  • Roux-en-Y jejunal limb creation
  • End-to-side anastomosis between the proximal bile duct and jejunum
  • Careful preservation of bile duct blood supply

3. Alternative Options (Not Recommended for This Case)

• Choledochoduodenostomy: Not preferred for injuries just above the duodenum due to higher risk of stricture formation
• Repair over T-tube: Only suitable for minor BDIs without tissue loss; high failure rate (not appropriate for complete transection) 2
• Choledochojejunostomy: Less commonly performed than hepaticojejunostomy for this type of injury

Timing of Repair

The timing of definitive repair is crucial:

• Early repair (within 72 hours) may be considered if:
  • Appropriate surgical expertise is available
  • Patient is hemodynamically stable
  • No significant inflammation is present 1
• Delayed repair is recommended for:
  • Complex injuries with significant inflammation
  • Vasculobiliary injuries
  • Unstable patients 1

Pitfalls and Caveats

1. Avoid primary repair attempts without expertise: Immediate repair attempts by non-HPB surgeons are associated with poorer outcomes 3

2. Beware of associated vascular injuries: Always assess for concurrent right hepatic artery injury, which may complicate management

3. Conversion to open surgery is not always protective: Simply converting to open surgery without changing the surgical strategy may not prevent or help repair the injury 4

4. Avoid multiple repair attempts: Failed initial repairs significantly worsen long-term outcomes

5. T-tube repairs for complete transections have high failure rates: Studies show that duct-to-duct repairs over T-tubes for complete transections have poor outcomes, with most patients eventually requiring hepaticojejunostomy 2

Long-term Considerations

Patients who undergo hepaticojejunostomy for CBD injury require:

• Long-term follow-up for potential stricture development
• Monitoring of liver function tests
• Assessment for cholangitis episodes
• Evaluation for quality of life impacts

By following this approach and prioritizing referral to specialized HPB centers when needed, the best long-term outcomes can be achieved for this serious surgical complication.