Bile Duct Injury Classifications That Include Vascular Components
The ATOM classification and Hannover classification are the most comprehensive bile duct injury classification systems that include vascular components, with ATOM being the most recent and recommended by the World Society of Emergency Surgery guidelines. 1, 2
Major Classification Systems with Vascular Components
The ATOM classification (Anatomical, Timing, and Mechanism) is the most recent and complete classification system for bile duct injuries, integrating anatomical damage, time of detection, and mechanism of injury while including vascular involvement through the "VBI+" designation (vasculobiliary injury) 1, 2
The Hannover classification specifically addresses vascular injuries alongside biliary damage, demonstrating a highly significant association between injury patterns and surgical treatment approaches 3, 4
The Stewart-Way classification integrates vascular injuries into bile duct injury descriptions, recognizing the critical importance of combined injuries 2, 5
The Lau classification includes vascular injury components, acknowledging their impact on management decisions 2, 5
Clinical Significance of Vasculobiliary Injuries
Concomitant vascular injuries, particularly to the hepatic artery, are common with complex biliary injuries and significantly impact treatment approach and outcomes 6, 4
Additional vascular involvement was found in 19% of bile duct injuries in one study, highlighting the importance of classifications that include this component 3
Systematic immediate repair of isolated injuries to the right hepatic artery is not recommended, and the benefit/risk ratio should be carefully evaluated on a case-by-case basis 1, 6
The repair of complex vasculobiliary injuries should be delayed rather than attempted intraoperatively, even by expert hepatopancreatobiliary (HPB) surgeons 1, 6
Limitations of Other Classification Systems
The Strasberg classification, despite being the most commonly used, does not consider vascular involvement, which is a significant limitation 2, 5
The Bismuth classification (1982), which was the first published classification system, focuses solely on biliary injury location without addressing vascular components 2, 5
The Neuhaus classification also does not consider vascular involvement, limiting its utility in comprehensive injury assessment 3, 5
WSES Guideline Recommendations
The World Society of Emergency Surgery (WSES) guidelines strongly recommend knowing both Strasberg's classification (most commonly used) and the ATOM classification (most recent and complete) 1
The guidelines specifically state that "the implementation of the ATOM classification should be promoted in the near future" due to its comprehensive nature 1
When describing bile duct injuries, the operative report must include detailed information about anatomical landmarks, variations, and any vascular structures involved 1
Clinical Implications
Proper classification of bile duct injuries with vascular components is essential for determining appropriate management strategies, timing of repair, and surgical approach 2
Vascular injuries significantly impact the extent of surgical intervention required and should be reflected in any classification system used 3, 4
The management complexity of patients with combined biliary and vascular injuries requires referral to specialized centers with expertise in hepatobiliary surgery 7, 4