What are the different types of biliary injuries and their possible management strategies?

Biliary Injury Types and Management

Classification of Biliary Injuries

Biliary injuries are best classified using the ATOM system, which integrates anatomical damage, timing of detection, and mechanism of injury, and should guide your management approach. 1

Anatomical Classification

Main Biliary Duct (MBD) Injuries:

• Classified by anatomical level (1-6) and described as complete (C) or partial (P) 1
• Loss of substance (LS) is documented when present 1
• Vasculobiliary injury (VBI) status is critical: VBI+ indicates associated vascular injury to right hepatic artery (RHA), left hepatic artery (LHA), common hepatic artery (CHA), portal vein (PV), or mesenteric vein (MV) 1

Non-Main Biliary Duct (NMBD) Injuries:

• Peripheral intrahepatic duct injuries 1
• Gallbladder injuries 2

Timing-Based Classification

Early Intraoperative (Ei):

• Detected during the index operation 1

Early Postoperative (Ep):

• Detected within days to weeks after surgery 1

Late (L):

• Detected weeks to months after injury, often presenting as strictures 1, 2

Mechanism Classification

Mechanical (Me):

• Direct surgical trauma from instruments, clips, or transection 1

Energy-Driven (ED):

• Thermal injury from electrocautery or other energy devices 1

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Management by Injury Type

Minor Bile Duct Injuries (Partial, No Tissue Loss)

These injuries result from electrocautery burns or partial cuts and can typically be repaired primarily. 1

Management approach:

• Direct repair with fine sutures (5-0 or 6-0) using single-layer technique 1
• T-tube placement may be considered for decompression 1, 3
• Abdominal drain placement is essential 1
• Success rate approaches 96% with appropriate management 4

Major Bile Duct Injuries (Complete Transection or Tissue Loss)

Roux-en-Y hepaticojejunostomy is the definitive treatment for major bile duct injuries with tissue loss, achieving 80-90% success rates when performed by experienced surgeons. 1

Timing considerations:

• If detected intraoperatively: Immediate repair ONLY by experienced biliary surgery specialists 1, 3
• If specialist unavailable: Place drainage and transfer to specialist center 3
• If detected early postoperatively without inflammation: Primary repair can be performed 3
• If infection, peritonitis, or vascular injury present: Delay definitive repair for 4-6 weeks after controlling bile leakage and infection 1, 3

Technical principles for hepaticojejunostomy:

• Remove all clips and scar tissue from proximal bile duct stump 1
• Anastomose only healthy, non-ischemic, non-inflamed, non-scarred bile duct tissue 3
• Use fine sutures (5-0 or 6-0) with single-layer technique, uniform margins, appropriate density, moderate knotting strength, and tension-free anastomosis 1
• For bilateral hepatic duct injuries, suture medial margins of left and right ducts together before jejunal anastomosis 1

Bile Leaks (Strasberg Type A)

Endoscopic management with biliary stenting is the first-line treatment for bile leaks, with 96% success rates. 4

Management algorithm:

• Minor leaks (<400 mL/day or resolving within 14 days): Conservative management with observation 5
• Major leaks (>400 mL/day or persistent >14 days): Endoscopic retrograde cholangiography (ERC) with biliary stent placement 2, 5
• Percutaneous drainage for associated bilomas 6, 5
• Broad-spectrum antibiotics if biloma, fistula, or peritonitis present 3

Evidence shows 65% of intrahepatic bile leaks are minor and resolve with conservative management alone, while 35% require endoscopic intervention. 5

Bilomas and Abscesses

Symptomatic or infected bilomas require percutaneous drainage as first-line treatment. 6

Management approach:

• Percutaneous drainage under imaging guidance 6, 7
• Broad-spectrum antibiotics 3
• Combined percutaneous drainage and endoscopic stenting for complex cases not suitable for percutaneous management alone 6
• Intrahepatic abscesses are successfully treated with percutaneous drainage 6

Delayed Biliary Fistulas

Percutaneous lavage/drainage combined with endoscopic stenting is the first-line approach for delayed post-traumatic biliary fistulas without other indications for laparotomy. 6

Management sequence:

• Percutaneous drainage of fluid collections 6
• Endoscopic biliary stenting to reduce biliary pressure and promote healing 6
• Stenting duration >6 months associated with better outcomes (P < 0.01) 4

Vasculobiliary Injuries (VBI+)

Complex vasculobiliary injuries should be delayed rather than attempted intraoperatively, even by expert hepatopancreatobiliary surgeons. 1

Management principles:

• Systematic immediate repair of isolated right hepatic artery injuries is NOT recommended 1
• Evaluate benefit/risk ratio on case-by-case basis 1
• Management depends on evidence and extent of liver injury (ischemia, necrosis, or atrophy) 3
• Delay definitive repair until inflammation controlled 1, 3

Gallbladder Injuries

Cholecystectomy is the definitive treatment for traumatic gallbladder injuries. 2

Approach:

• Laparoscopic cholecystectomy preferred when feasible 2
• Open cholecystectomy during damage control laparotomy if hemodynamically unstable 2

Late Strictures

Patients with ductal injuries are at higher risk for stricture formation and require close follow-up. 2

Management options:

• Percutaneous transhepatic dilation and stent placement 7
• Endoscopic dilation and stenting 7
• Surgical revision with hepaticojejunostomy for refractory strictures 2
• Hepatectomy reserved for cases with chronic complications like liver abscess, secondary hepatolithiasis, or failed reconstruction 3, 2

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Critical Management Principles

Complete imaging of the biliary tree is essential before definitive repair using percutaneous transhepatic cholangiography (PTC), MRCP, or other appropriate modalities. 3, 7

The fundamental principle: anastomosis and reconstruction must use only healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue—failure to follow this principle is the primary cause of repair failure. 3

Outcomes are best with surgical management by experienced biliary surgeons (88% success) compared to endoscopy (76%) or interventional radiology (50%), and have improved significantly in recent years (95% vs 80%, P < 0.05). 4