How to manage a completely transected 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) is the treatment of choice for complete transection of the common bile duct (CBD) just above the duodenum during laparoscopic cholecystectomy. 1

Rationale for Hepaticojejunostomy

The management of bile duct injuries depends on the type, location, and extent of injury. For major bile duct injuries with complete transection (Strasberg type E), hepaticojejunostomy is strongly recommended as the definitive treatment:

• The 2020 World Society of Emergency Surgery (WSES) guidelines specifically state that "hepaticojejunostomy should be considered the treatment of choice in cases of major BDIs" with strong recommendation despite low quality of evidence (GRADE 1C) 1

• Complete transection of the CBD represents a major bile duct injury that requires complex reconstruction, as it is associated with tissue loss and cannot be repaired primarily

Management Algorithm

Immediate Recognition During Surgery

1. Initial steps:

   • Place a drain in the right upper quadrant
   • Document the injury precisely (location, extent, associated vascular injury)
   • Avoid further dissection in the hilum that may cause additional damage

2. Decision on repair timing:

   • If HPB (hepato-pancreato-biliary) expertise is available on-site:

     • Early repair (on-table or within 72 hours) may be considered 1
     • Hepaticojejunostomy is the procedure of choice for complete CBD transection

   • If HPB expertise is not available:

     • Place drains and refer to an HPB center immediately
     • Do not attempt repair without appropriate expertise as this worsens outcomes 1

Delayed Recognition (Within 72 Hours)

1. Initial management:

   • Control biliary drainage with percutaneous drains
   • Administer antibiotics if signs of infection
   • Urgent referral to an HPB center

2. Definitive treatment:

   • Hepaticojejunostomy (Roux-en-Y) performed by experienced HPB surgeons 1, 2

Late Recognition (Beyond 72 Hours)

1. Initial management:

   • Percutaneous drainage of any collections
   • Antibiotics for infection/sepsis
   • Nutritional support

2. Definitive treatment:

   • Delayed hepaticojejunostomy (after 3-6 months) once inflammation subsides 2

Why Not Other Options?

• Choledochoduodenostomy (Option B): Not recommended for high bile duct injuries or complete transections due to higher risk of reflux cholangitis and stricture formation

• Repair over T-tube (Option C): Only suitable for minor injuries with partial transection. For complete transection, primary repair over T-tube has high failure rates (up to 64%) 1, 3

• Choledochojejunostomy (Option A): This refers to anastomosis of the common bile duct to jejunum, which is not appropriate when the injury is at the level of the common hepatic duct or higher

Important Considerations

• Vascular injury assessment: Always evaluate for concomitant vascular injuries (particularly right hepatic artery), as they significantly worsen outcomes 3

• Expertise matters: Outcomes are significantly better when repairs are performed by experienced HPB surgeons at specialized centers 1, 2

• Timing considerations: While early repair by experienced surgeons can yield good results, attempting repair in the setting of inflammation or by inexperienced surgeons leads to poorer outcomes 1

• Long-term follow-up: Even with appropriate repair, patients require long-term follow-up due to risk of late stricture formation (up to 32.3% in some series) 4

By following this approach, the reported success rate for bile duct injury repair at specialized centers is 93-97% 3, 2, though some patients may require subsequent interventions for strictures.