How to manage a completely transected common bile duct (CBD) just above the duodenum during a laparoscopic cholecystectomy?

Management of Complete Common Bile Duct Transection During Laparoscopic Cholecystectomy

For a completely transected common bile duct (CBD) just above the duodenum during laparoscopic cholecystectomy, hepaticojejunostomy is the recommended treatment of choice. 1

Assessment of the Injury

• Complete transection of the CBD represents a major bile duct injury (BDI) requiring careful management to prevent long-term complications 1
• The location of the injury (just above the duodenum) indicates a distal CBD injury, which influences the repair strategy 1

Management Algorithm

Immediate Management

1. Recognize the injury and assess its extent

   • Complete documentation of the injury including anatomical level and vascular involvement 1
   • Consider obtaining another surgeon's opinion if available 1

2. Decision on immediate repair vs. referral

   • If HPB (hepato-pancreato-biliary) expertise is available locally:
     • Early repair (within 72 hours) may be considered 1
   • If HPB expertise is not available:
     • Place abdominal drains to control bile leakage 1
     • Immediate referral to a center with HPB expertise 1

Definitive Surgical Management

Hepaticojejunostomy (Option D) is the correct answer for the following reasons:

• Hepaticojejunostomy is the treatment of choice for major bile duct injuries with complete transection 1
• This procedure provides the best long-term outcomes for major BDIs with the lowest rate of stricture formation 1
• The 2020 WSES guidelines strongly recommend hepaticojejunostomy for major BDIs (Grade 1C recommendation) 1

Why Other Options Are Not Recommended:

• Choledochojejunostomy (Option A): Not typically recommended for injuries at this location as hepaticojejunostomy provides better outcomes 1
• Choledochoduodenostomy (Option B): Associated with higher rates of complications including cholangitis and stricture formation compared to hepaticojejunostomy 1
• Repair over T-tube (Option C):
  • Only appropriate for minor BDIs without tissue loss 1
  • Direct repair with T-tube for complete transection has a high failure rate 2
  • The 2020 WSES guidelines specifically note that end-to-end anastomosis (including T-tube repair) is associated with increased failure rates compared to hepaticojejunostomy 1

Timing Considerations

• Early repair by an experienced HPB surgeon (within 72 hours) is associated with better outcomes 1
• However, a multi-center study showed that timing of hepaticojejunostomy (early, intermediate, or late) did not significantly impact outcomes when performed by experienced surgeons 3
• Complex injuries should be managed by surgeons with HPB expertise to minimize complications 1

Important Caveats

• Concomitant vascular injuries (particularly right hepatic artery) should be assessed, as they occur in up to 24% of cases and affect outcomes 4
• Systematic immediate repair of isolated vascular injuries is not recommended 1
• Patients referred late to a competent center have higher rates of serious infections (up to 70%) 4
• Proper documentation of the injury is essential for planning appropriate management 1

Long-term Outcomes

• Successful hepaticojejunostomy by experienced HPB surgeons results in good long-term outcomes with normal liver function in most patients 4
• Complications of bile duct injuries can include strictures, cholangitis, and rarely, liver failure 1
• Regular follow-up with liver function tests and imaging is recommended to detect late complications 4