What are the types of bile duct injury?

Types of Bile Duct Injury Classifications

The most widely used classifications for bile duct injuries are Strasberg's classification and the ATOM classification, with the latter representing the most recent and complete system that should be promoted for future use. 1

Major Classification Systems

Anatomical Location-Based Classifications

• Bismuth classification (1982) - the first published classification system focused on biliary injury location 1
• Strasberg classification (1995) - currently the most commonly used classification for BDIs 1
• Other location-based systems include McMahon, Bergman, Neuhaus, and Csendes classifications 1

Integrated Classifications (Including Vascular Injuries)

• Stewart-Way classification (2007) - integrates vascular injuries into BDI description 1
• Hannover classification - addresses vascular involvement and location of lesions at or above bifurcation 2
• Lau classification - includes vascular injury components 1
• ATOM classification (2013) - the most recent and comprehensive system that combines:
  • Anatomic damage
  • Time of detection
  • Mechanism of injury 1

Clinical Categorization of BDIs

Minor Bile Duct Injuries

• Injuries caused by electrocautery burns or partial cuts from sharp dissection 1
• No associated tissue loss 1
• Can typically be repaired primarily with sutures and abdominal drain placement 1

Major Bile Duct Injuries

• Associated with tissue loss (e.g., common bile duct clipped and transected) 1
• Require complex reconstruction with Roux-en-Y hepaticojejunostomy 1
• Examples include Strasberg type E injuries 1

Specific Classification Details

WSES Classification System

• Organizes injuries by severity (minor, moderate, severe) 1
• Includes pancreatic, duodenal, and extrahepatic biliary tree injuries 1
• For extrahepatic biliary injuries:
  • Minor (Class I): Gallbladder contusion/hematoma, partial avulsion, laceration/perforation, or complete avulsion 1
  • Moderate (Class II): Partial or complete duct lacerations of hepatic ducts or partial common bile duct laceration (<50%) 1
  • Severe (Class III): >50% transection of common hepatic/bile ducts, combined injuries, or intraduodenal/intrapancreatic injuries 1

Praxis Medical Insights Classification

• Categorizes bile duct injuries into Types I-III based on anatomical location 3
• Type I injuries: Can be treated with simple repair using Kocher incision or may require choledochojejunostomy for severe cases 3
• Type II injuries (subtypes 1-4): Treatment ranges from simple suture to duct-to-duct anastomosis or choledochojejunostomy 3
• Type III injuries: Can be managed with ligation/suture of injured duct or may require PTCD/endoscopic stent placement 3

Bismuth Type 4 Injury (Specific Subtype)

• Involves damage to first branches of hepatic duct at hilar plate level with involvement of secondary biliary branches 4
• Typically requires hepaticojejunostomy with Roux-en-Y reconstruction 4

Clinical Implications of BDI Classifications

Importance of Proper Classification

• Essential for choosing appropriate management strategy 1
• Helps determine timing of repair and surgical approach 3, 4
• Facilitates communication between healthcare providers 1

Limitations of Current Classifications

• No consensus on a "gold standard" classification for BDIs 1
• Direct comparisons between systems are difficult 1
• Lack standardization of common nomenclature 1
• Some systems (like ATOM) may be too complex for routine clinical practice 1

Management Considerations Based on Classification

• Intraoperative BDI should be repaired immediately only by experienced biliary surgery specialists 3
• For injuries detected early postoperatively without inflammation, primary repair can be performed 3
• In cases with infection, peritonitis, or vascular injury, delayed repair is recommended after controlling leakage and infection 3, 4
• Definitive repair is typically performed 4-6 weeks after effective control of inflammation 3, 4

Common Pitfalls in BDI Management

• Failure to use healthy, non-ischemic, non-inflamed tissue for reconstruction 3, 4
• Unclear boundaries of ischemia and devitalization from thermal injury 4
• Using scarred bile duct wall or surrounding tissue will lead to surgical failure 3, 4
• Overlooking associated vascular injuries, particularly to the hepatic artery 3, 4