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
• Complete transection of the CBD requires definitive surgical reconstruction, and hepaticojejunostomy performed by experienced hepatopancreatobiliary (HPB) surgeons provides the best outcomes 1
• Other options are less suitable for complete transection:
  • Choledochoduodenostomy is not recommended for complete transections due to higher risk of reflux cholangitis and stricture formation 1
  • Repair over T-tube has high failure rates (up to 64%) for complete transections and is only suitable for minor injuries with partial transection 1, 2
  • Choledochojejunostomy is not appropriate when the injury is at the level of the common hepatic duct or higher 1

Management Algorithm

1. Initial steps:

   • Control biliary drainage with percutaneous drains
   • Administer antibiotics if signs of infection are present
   • Assess availability of HPB expertise on-site 1

2. If HPB expertise is available on-site:

   • Early repair (on-table or within 72 hours) with hepaticojejunostomy may be considered 1
   • Timing is critical - early repair by experienced surgeons yields good results 1, 3

3. If HPB expertise is not available:

   • Place drains to control biliary leakage
   • Immediate referral to an HPB center is mandatory
   • Do not attempt repair without appropriate expertise as this significantly worsens outcomes 1

Important Considerations

• Expertise matters significantly - outcomes are substantially better when repairs are performed by experienced HPB surgeons at specialized centers 1, 4
• Attempting repair in the setting of inflammation or by inexperienced surgeons leads to poorer outcomes 1
• Even with appropriate repair, patients require long-term follow-up due to risk of late stricture formation 1
• Studies show success rates of 93-97% when managed appropriately at specialized centers 4, 5

Common Pitfalls to Avoid

• Attempting repair without HPB expertise
• Delaying referral to specialized centers
• Choosing inappropriate repair techniques for complete transection (T-tube repair or choledochoduodenostomy)
• Performing repair in the presence of active inflammation or peritonitis 1, 4
• Inadequate follow-up after repair, as late strictures can develop

In conclusion, for a completely transected CBD just above the duodenum during laparoscopic cholecystectomy, hepaticojejunostomy performed by experienced HPB surgeons represents the definitive management strategy with the best long-term outcomes.