Post-Laparoscopic Cholecystectomy Bile Duct Injury with Clips on CBD
The next step is to remove the clips surgically, as this represents a major bile duct injury (Strasberg E) requiring urgent referral to a hepatobiliary center for surgical repair with Roux-en-Y hepaticojejunostomy. 1
Immediate Management Priorities
Classification and Severity Assessment
- Clips placed on the CBD represent a major bile duct injury (Strasberg E1-E2), not a minor injury that can be managed conservatively 1
- The presence of jaundice and biloma indicates both biliary obstruction and bile leak, confirming a complete or near-complete CBD injury 1, 2
- This injury pattern results from misidentification of the common duct during laparoscopic cholecystectomy, the most common mechanism of major BDI 2, 3
Timing-Based Treatment Algorithm
If diagnosed within 72 hours postoperatively:
- Urgent referral to a hepatobiliary center with expertise in HPB procedures is mandatory 1
- Surgical repair with clip removal and Roux-en-Y hepaticojejunostomy should be performed urgently 1
- Immediate duct-to-duct repair over a T-tube has a high failure rate and should be avoided 2
If diagnosed between 72 hours and 3 weeks:
- Percutaneous drainage of the biloma is the first step 1
- Targeted antibiotics and nutritional support during this stabilization period 1
- ERCP with sphincterotomy ± stent can be considered to reduce biliary pressure gradient, but this is temporizing only 1
- After minimum 3 weeks of stabilization, proceed with Roux-en-Y hepaticojejunostomy 1
Why Other Options Are Incorrect
US-Guided Aspiration Alone (Option A)
- Aspiration without addressing the underlying CBD obstruction from clips will result in persistent bile leak and recurrent biloma 1
- This is appropriate only for minor injuries (Strasberg A-D) as a temporizing measure, not for major CBD injuries 1
ERCP Alone (Option C)
- ERCP cannot remove clips from the CBD 1
- While ERCP with sphincterotomy and stenting can reduce biliary pressure and may help control minor leaks, it cannot resolve complete CBD obstruction from clips 1
- ERCP is useful as an adjunct in the 72-hour to 3-week window but is not definitive treatment 1
Follow-up and Hydration (Option D)
- Conservative management is contraindicated for major BDI with CBD obstruction 1
- This approach will lead to progressive cholangitis, biliary cirrhosis, and potential mortality 2, 4
Definitive Surgical Management
Roux-en-Y hepaticojejunostomy is the procedure of choice:
- Long-term success rates exceed 80% in most series 4
- This provides complete access to the ductal system and definitive repair 5, 4
- Twenty of 21 patients in one series required hepaticojejunostomy for definitive treatment after initial attempts at simpler repairs failed 2
Critical Pitfalls to Avoid
- Do not attempt duct-to-duct repair over T-tube as primary treatment - this has high failure rates for major injuries 2
- Do not delay referral to an HPB center - early recognition and appropriate referral significantly improve outcomes 1
- Do not rely on ERCP as definitive treatment when clips are obstructing the CBD 1
- Ensure proper radiographic visualization with percutaneous transhepatic cholangiography (PTC) or MRCP to define proximal biliary anatomy before reconstruction 2, 3, 4