Training material II
Extrahepatic biliary injuries
The vast majority of extrahepatic biliary injuries are iatrogenic, and they have been increasing in recent years, with an incidence rate at about 2–3% (1 out of 300–500 gallbladder surgeries). Of the iatrogenic bile duct injuries, 90% are found in cholecystectomy, 5% in common bile duct exploration, 3% in subtotal gastrectomy, and 2% in duodenal diverticulum resection. In the operation of portacaval shunt and pancreas, if the biliary tract injury is not detected and treated in time during the operation, the consequences are often very serious, which must arouse the surgeon's high attention.
1. Factors causing iatrogenic bile duct injury
1.1 Anatomical factors: There are many anatomical variations of biliary tract, and ignorance of them is likely to cause biliary tract injury.
- The cystic duct is too short, or even the neck of the gallbladder is directly connected with the common bile duct, these are likely to lead to the procedure error in mistaking the common bile duct as the cystic duct during ligation.
- The cystic duct is too long and it runs parallel to the common bile duct. Tightly clinging to the common bile duct, it flows downward into the common bile duct in the rear of duodenum or head of pancreas. It is easy to cause accidental injury to the common bile duct when separating the cystic duct.
- When the cystic duct opens from the right hepatic duct or the right hepatic duct flows into the cystic duct, the right hepatic duct is liable to be injured by mistake if the situation is not identified well.
- If the cystic duct is not in the normal position and passes around behind or before the common hepatic duct by 180 and 360 degrees, flowing into the common hepatic duct while both the cystic duct and he common hepatic duct are in the same connective tissue capsule, it is prone to inflammatory adhesion. In such situations, the common hepatic duct may be easily injured by mistake when attempting to separate them by force.
- When the pathway of gallbladder artery or right hepatic artery is abnormal, hemorrhage occurs due to injury during operation. Common hepatic duct and common bile duct can be injureddue to clamping or suture hemostasis in a hurry.
1.2 Pathological factors
- Acute inflammation, congestion, edema and adhesion lead to unclear local anatomical relationships, fragile tissue, easy damage can be caused by pulling, clamping and separation during the surgery.
- When chronic inflammation occurs repeatedly, scar adhesion can cause bile duct shift (scar contraction and traction). If the operator fails to pay attention, forced separation will easily cause biliary tract injury.
1.3 improper operation technology and errors:
- The incision is too small, resulting in poor exposure, organ traction and bile duct shift.
- When the gallbladder is removed, excessive traction result in damages to the common hepatic duct or common bile duct wall.
- If there is bleeding from the gallbladder artery or right hepatic artery during the operation, blindly clamping or sewing causes damages.
- Local inflammatory scar adhesion, with unclear anatomical relationships, forcibly separating at hepatic hilus or Calot trigone can cause injury.
- Exploration of biliary tract or stone removal with excessive force can cause laceration of hepatic duct or lower segment of common bile duct, or a puncture in bile duct wall.
- The posterior wall of common bile duct is accidentally injured when the common bile duct is cut open.
- With ulcer of corpus callosum in duodenal bulb, scar contraction, shortening of the interval between pylorus and common bile duct, forced separation during subtotal gastrectomy is likely to cause common bile duct damage.
- Many vascular forceps are reserved deep and not removed with timely ligation, the injury is caused easily by "touching" or "bumping" with the vascular forceps.。
1.4 Attention required to the cultivation of surgeons’ skills:
- Accidental injury follows the lack of strong sense of responsibility, carelessness, and failure to conduct meticulous dissection to identify the relationship between the cystic duct and common hepatic duct while removing the cyst.
- Over-pursuing speed, blind separation, and massive ligation are all possible causes for the injury.
- In case of accidents during operation, the operator is not self-possessed and operates blindly in panic.
2 Clinical manifestations
Some cases of bile duct injury are found during the operation and treated in time, but most cases are only definitely diagnosed after the operation when the following symptoms and signs start to appear.
2.1. Abdominal pain: pain in the right upper abdomen spreading to the whole abdomen, with peritoneal irritation. Distending pain in liver area, increased internal pressure of bile duct with ligated bile duct.
2.2. Jaundice: complete ligation of bile ducts and aggravation of jaundice in the early stage. Partial ligation of bile duct, with stricture of bile duct causes mild jaundice or no jaundice temporarily. Bile duct injury or stenosis is often followed by bile duct infection and jaundice.
2.3. External biliary fistula: when the abdominal drainage tube is placed, a large amount of bile may flow out.
2.4. Cold and fever: common manifestations of biliary peritonitis or secondary cholangitis, leading to shock in severe cases.
2.5. Laboratory tests: white blood cells increase and neutrophils increase. Serum bilirubin and alkaline phosphatase may increase.
3. Diagnosis:
3.1. During the operation: The diagnosis rate during the operation accounts for 15–20% of all diagnoses according to the statistics. When seeing bile on the operation wound (seeable when using clean gauze to wipe the wound) or observing liquid leakage in bile duct flushing, the operator needs to carefully check for a clear diagnosis, with timely treatment. Intra-operative cholangiography may assist in the definitive diagnosis in those difficult cases (situations like bile duct rupture, broken end or bile duct sutured).
3.2. In postoperative hospitalization: the diagnosis is not difficult according to the typical clinical manifestations.
3.3. After discharge from hospital: it refers to partial ligation with injury of common bile duct. Usually there are no obvious symptoms in the near future after operation. The wound heals in one stage. There are no signs of biliary peritonitis because the bile duct injury is non-open. Jaundice does not occur either because there is no obstruction of the biliary lumen. However, several months or even years later, due to the injury, stenosis, infection, and cicatricial stenosis, the bile duct gradually becomes thinner, and the biliary flow is no longer smooth, repeated episodes of biliary tract infection appear. This is easily misdiagnosed as "residual stones" in clinical practice, and the definitive diagnosis is indeed difficult. Percutaneous transhepatic cholangiography is an important means to assist examination.
4. Treatment
Once the diagnosis is established, it should be actively treated.
4.1. Timely treatment when injury is found during the operation. When found within 24 hours after the operation, perform emergency surgical treatment when the organization is still healthy, with no serious infection, edema, adhesion. More specifically:
- In cases where the injury is small in scope, and there is no or little tension in the anastomosis, transverse suture should be performed with the distal T-tube supporting drainage. The tube should be kept for no less than three months after operation.
- In cases with transverse injury (on common bile duct), with local inflammation insignificant, without tension after anastomosis (including Kocher incision and loosening duodenum), end-to-end anastomosis can be performed, with a T-tube placed at the distal end to support draining the wound. The tube shall be placed for 3–6 months after operation.
- In cases with numerous common bile duct injuries (especially with injuries larger than 2cm), with high tension after anastomosis, treatment is a challenge, with high risk of failure. Ligation of common bile duct at the distal end and internal biliary-intestinal drainage at the proximal end (Roux-y technique) can be performed to save the case.
4.2. If bile duct injury is found recently after operation, we should try our best to operate within 7–10 days. The operation can be expected to be successful within 7 days after operation. After more than 10 days, local congestion, edema, fragile tissue, adhesion, unclear anatomy, difficult operation, and low success rate, we should first external biliary drainage, and then operate after the inflammation subsides for 3–6 months.
2. 术后近期发现胆管损伤，宜力争在 7-10 天内手术，术后7天内手术可望获得成功。在10天以上，局部充血、水肿，组织脆弱、粘连，解剖不清，操作难度大，成功率低，宜先行胆道外引流，待炎症消退 3-6 个月后再手术。
3. 术后后期诊断胆管损伤性狭窄，也应争取早期手术。因反复发作胆管炎，肝功能损害，继发胆汁性肝硬化，门静脉高压死于上消化道出血或肝昏迷，故应创造条件，争取尽早修复重建。
● 胆肠内引流，肝外胆管较长且扩张，行胆肠 Roux-y 吻合。
● 高位胆管狭窄，肝外胆管较短已无吻合余地，则可行左肝内肝管空肠 Roux-y 吻合术，但应明确左右肝管汇合通畅方可施行。
“Y”吻合旷置肠段在 40-60cm 左右，基本上可无逆行胆道感染发生。
4.3. Early operation should be carried out for the diagnosis of bile duct injury stenosis in the late stage after operation. Because of repeated attack of cholangitis, liver damage, secondary biliary cirrhosis, portal hypertension died of upper gastrointestinal bleeding or hepatic coma, so we should create conditions for early repair and reconstruction. (i) Choledocho-intestinal drainage, long and dilated extrahepatic bile ducts, and choledocho-intestinal Roux-y anastomosis was performed. (ii) If the high bile duct is narrow and the extrahepatic bile duct is short and there is no room for anastomosis, Roux-y left intrahepatic hepatic hepatic jejunal anastomosis may be performed, but it should be clear that the left and right hepatic ducts are confluent and unobstructed before implementation. The size of the "Y" anastomosed open bowel segment is about 40–60 cm, and basically no retrograde biliary tract infection occurs.
1. 适当的切口，良好的麻醉, 肌肉松驰，暴露良好，必要时延长切口或果断改硬膜外阻滞为全麻。
2. 术中应仔细辨认胆囊动脉、胆囊管、肝总管、胆总管的行径和关系，因肝外胆道变异较多，一切组织在未弄清鲜剖关系之前，切勿盲目钳夹、结扎、切断。
3. 争取顺行切除胆囊，但若炎症、水肿、严重粘连、Calot 三角解剖困难，不应强行分离，应改行从胆囊底部开始剥离的逆行法切除胆囊。若仍困难，不得己时则可行胆囊大部切除术，同样可达到切除胆囊之目的。
4. 在两针牵引线间切开胆总管探查时，二针缝线距离不宜过大，以免后壁一同被牵拉，切开时尖刀系“切割开”胆总管前壁而非“刺入”前壁，以免造成后壁损伤。
5. 胃大部切除术，若遇胼胝性十二指肠球部溃疡，由于炎性粘连、疤痕收缩，解剖关系改变，胆总管-幽门间距离缩短，在幽门上方分离时慎防损伤胆总管，在估计困难时应果断改行溃疡旷置 Bancroft 术，可避免误伤胆总管。
6. 术中遇胆囊动脉出血，应采用左手食指置 Winslow 孔内。左拇指在前压迫肝十二指肠韧带，吸净出血后，松开压力观察出血处进行止血，切忌盲目钳夹，缝扎，导致误伤。
7. 探查胆总管下端或左右肝管，(探查，取石) 用力不宜过大，动作不应粗暴，以免造成胆管或括约肌撕裂基至形成戳穿胆管壁造成假道。
8. 熟悉胆道解剖变异，术中时时警惕医源性胆道损伤的可能性，认真、细致操作，摒弃医源性胆道损伤的因素，预防胆管损伤的发生。认织胆管损伤的表现，及时正确处理，使胆管损伤给病人带来的危害降到最低限度，普外科医师在胆囊手术上失误还是比较多的，开好一个胆囊不难，一辈子工作中做好每一个胆囊亦非易事! 同行们，愿我们共同努力。
5. Prevention
Prevention is more important than treatment.
5.1. The appropriate incision, good anesthesia, muscle relaxation, good exposure, when necessary to extend the incision or decisive change epidural block for general anesthesia.
5.2. During the operation, the behaviors and relationships of gallbladder artery, cystic duct, common hepatic duct and common bile duct should be carefully identified. Due to more variation of extrahepatic biliary ducts, all tissues should not be clamped, ligated and cut off blindly before the fresh section relationship is clarified.
5.3. For anterograde cholecystectomy, but if the inflammation, edema, severe adhesion, difficult to dissect the Calot triangle, should not be forced to separate, should be diverted from the bottom of the gallbladder stripping retrograde cholecystectomy. If it is still difficult and inappropriate, subtotal cholecystectomy can be performed, which can also achieve the purpose of gallbladder resection.
5.4. When cutting the common bile duct between the two traction wires for exploration, the distance between the two stitches should not be too large, so as to avoid the posterior wall being pulled together. When cutting, the sharp knife "cuts" the anterior wall of common bile duct rather than "pierces" the anterior wall, so as to avoid the damage to the posterior wall.
5.5. For subtotal gastrectomy, in case of callosal duodenal bulbar ulcer, due to inflammatory adhesion, scar contraction, and changes in anatomical relationship, the distance between common bile duct and pylorus is shortened, so we should be careful to prevent damage to common bile duct when separating above pylorus. When estimation is difficult, we should resolutely switch to ulcer exclusion Bancroft technique to avoid accidental damage to common bile duct.
5.6. In case of gallbladder artery bleeding during the operation, the left index finger should be used to place the Winslow foramen. The left thumb was used to compress the hepatoduodenal ligament in the anterior direction, and after the hemorrhage was sucked out, the pressure was released to observe the bleeding site for hemostasis. It is forbidden to clamp and sew blindly, resulting in accidental injury.
5.7. Explore the lower end of the common bile duct or left and right hepatic duct, (exploration, stone) force should not be too big, the action should not be rough, so as not to cause bile duct or sphincter tear base to form puncture bile duct wall cause false way.
5.8. Be familiar with the anatomical variation of biliary tract, intraoperative always alert to the possibility of iatrogenic bile duct injury, careful and meticulous operation, abandon the factors of iatrogenic bile duct injury, prevent the occurrence of bile duct injury. Recognize weave bile duct damage performance, timely and correct treatment, make bile duct damage to the patient's harm to a minimum, general surgeons mistakes in gallbladder surgery or more, open a gallbladder is not difficult, a lifetime work to do a good job in every gall bladder is not easy! Colleagues, may we make joint efforts.
This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30 Changhang Hospital, Li Mingjie
from 外科截瘫14例手术分析
