What is the most appropriate next step in managing a patient with a biliary injury, specifically a divided hepatic duct with clips on the proximal hepatic duct and distal common bile duct, and where are bile salts primarily absorbed in the enterohepatic circulation?

Management of Bile Duct Injury During Laparoscopic Cholecystectomy and Bile Salt Absorption

Management of Biliary Injury

Hepaticojejunostomy is the most appropriate next step for managing a divided hepatic duct with clips on the proximal hepatic duct and distal common bile duct. 1, 2

The scenario describes a major bile duct injury detected intraoperatively with:

• Divided hepatic duct
• Clips on proximal hepatic duct
• Clip on distal common bile duct
• No filling of proximal common hepatic duct on cholangiogram

This represents a severe bile duct injury requiring definitive reconstruction:

• Major bile duct injuries with tissue loss and transection require Roux-en-Y hepaticojejunostomy as the recommended method of reconstruction 1, 2

• For cases with clips on the bile ducts and complete transection, end-to-end anastomosis is not recommended due to high risk of stricture formation 1, 2

• Hepaticojejunostomy provides the best long-term outcomes for major bile duct injuries with success rates of 80-90% when performed by experienced surgeons 3

• The procedure involves removing clips and scar tissue from the proximal bile duct stump and creating an anastomosis between healthy bile duct tissue and a Roux-en-Y jejunal limb 1

Technical Considerations for Hepaticojejunostomy

• The key to successful hepaticojejunostomy is establishing an adequate caliber of anastomosis using a narrow proximal bile duct with normal mucosa 1

• Scar tissue on the stump of the bile duct must be removed after fully exposing the proximal bile duct 1

• For cases where left and right hepatic ducts are cut off, remove scar tissue from bile duct stumps and form an anastomotic stoma by suturing the medial margin of left and right hepatic ducts before performing anastomosis with the jejunum 1

• Use fine suture technique (5-0 or 6-0) according to the thickness of the bile duct wall, with either absorbable or non-absorbable sutures 1

• Principles of single-layer stitching, uniform margins, appropriate density, moderate knotting strength, and tension-free anastomosis should be followed 1

Why Other Options Are Not Appropriate

• End-to-end anastomosis with absorbable suture (option B) is not recommended for major bile duct injuries with tissue loss or when clips have been placed on the ducts 1, 2

• Choledochojejunostomy (option A) is not appropriate when the injury involves the hepatic duct rather than the distal common bile duct 1, 4

• Whipple procedure (option D) would be excessive for an isolated bile duct injury without pancreatic or duodenal involvement 1, 4

Enterohepatic Circulation of Bile Salts

The majority of bile salts are absorbed in the terminal ileum during enterohepatic circulation.

The enterohepatic circulation of bile involves:

• Bile salts are synthesized in the liver, secreted into bile, and stored in the gallbladder 2

• After meal stimulation, bile is released into the duodenum and travels through the small intestine 2

• Approximately 95% of bile salts are reabsorbed in the terminal ileum through active transport mechanisms 2

• The remaining 5% of bile salts that escape absorption in the terminal ileum may be modified by bacteria in the colon and partially reabsorbed there 2

• Absorbed bile salts return to the liver via the portal vein, where they are efficiently extracted and resecreted into bile 2

• This enterohepatic circulation occurs 6-10 times daily 2