Management of Complete Common Bile Duct Transection During Laparoscopic Cholecystectomy
Hepaticojejunostomy (Roux-en-Y) is the procedure of choice for complete transection of the common bile duct 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, despite the low quality of evidence (GRADE 1C) 1. This approach provides the best long-term outcomes when performed by experienced hepatobiliary (HPB) surgeons.
Management Algorithm
Initial Management:
- Control biliary drainage with percutaneous drains
- Administer antibiotics if signs of infection are present
- Urgent referral to an HPB center 1
Timing of Repair:
- Early repair (on-table or within 72 hours) may be considered ONLY if HPB expertise is available on-site
- If HPB expertise is not available, place drains and immediately refer to an HPB center 1
- Attempting repair without appropriate expertise significantly worsens outcomes
Definitive Treatment:
- Hepaticojejunostomy (Roux-en-Y) performed by experienced HPB surgeons 1
Why Other Options Are Not Recommended
Choledochoduodenostomy (Option B): Not recommended for complete transections due to higher risk of reflux cholangitis and stricture formation 1
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. T-tube repair is more appropriate for managing residual stones rather than complete transection 2
Choledochojejunostomy (Option A): Not appropriate when the injury is at the level of the common hepatic duct or higher 1
Important Considerations
Expertise Matters: Outcomes are significantly better when repairs are performed by experienced HPB surgeons at specialized centers 1
Avoid Common Pitfalls:
- Do not attempt repair without HPB expertise
- Do not perform repair in the setting of active inflammation or peritonitis
- Do not choose repair over T-tube for complete transection
Long-term Follow-up: Even with appropriate repair, patients require long-term follow-up due to risk of late stricture formation 1
Complications: Studies show that even with optimal management at tertiary centers, approximately 32.3% of patients may develop late postoperative complications including stricture and cholangitis 3
The evidence strongly supports hepaticojejunostomy as the definitive treatment for complete CBD transection, with the best outcomes achieved when performed by experienced HPB surgeons at specialized centers.