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 procedure of choice for managing a completely transected common bile duct (CBD) just above the duodenum during laparoscopic cholecystectomy. 1

Rationale for Hepaticojejunostomy

The World Society of Emergency Surgery (WSES) guidelines strongly recommend hepaticojejunostomy as the treatment of choice for major bile duct injuries with complete transection (GRADE 1C recommendation) 1. This approach is preferred because:

• It provides the most reliable long-term results for complete CBD transection
• It avoids the higher risk of reflux cholangitis and stricture formation associated with choledochoduodenostomy
• It is appropriate for injuries at all levels of the biliary tree, including those near the duodenum

Management Algorithm

Immediate Steps

1. Control biliary drainage with placement of percutaneous drains
2. Administer antibiotics if signs of infection are present
3. Urgently refer to a hepatopancreatobiliary (HPB) center 1

Definitive Management

• If HPB expertise is immediately available:

  • Early repair (on-table or within 72 hours) with hepaticojejunostomy may be considered 1

• If HPB expertise is not available:

  • Place drains to control biliary drainage
  • Do NOT attempt repair locally
  • Transfer immediately to an HPB center 1

Why Other Options Are Not Recommended

1. Choledochoduodenostomy (Option B): Not recommended for complete transections due to higher risk of reflux cholangitis and stricture formation 1

2. Repair over T-tube (Option C): Only suitable for minor injuries with partial transection. Has high failure rates (up to 64%) for complete transection 1. Studies show T-tube repair is primarily used for residual stones rather than complete transections 2

3. Choledochojejunostomy (Option A): This term is sometimes used interchangeably with hepaticojejunostomy but technically refers to a more distal anastomosis. For complete transection, hepaticojejunostomy is the specific procedure of choice 1

Important Considerations

• Expertise matters significantly: Outcomes are substantially better when repairs are performed by experienced HPB surgeons at specialized centers 1, 3

• 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, 4

• Risk factors for poor outcomes:

  • Previous repair attempts before referral
  • Combined bile duct and hepatic artery injury
  • Reconstruction in the setting of peritonitis 3

• Long-term follow-up: Even with appropriate repair, patients require long-term follow-up due to risk of late stricture formation (occurring in approximately 32% of patients) 1, 5

Pitfalls to Avoid

• Do not attempt repair without appropriate HPB expertise - this worsens outcomes significantly 1
• Do not delay referral to an HPB center - early referral is associated with better outcomes 5, 4
• Do not use choledochoduodenostomy for complete transections due to higher complication rates 1
• Do not attempt primary repair over T-tube for complete transections due to high failure rates 1