BILIARY SURGERIES

Presentor: Georvin Marco

Supervisor :Dr. Mwanga
 outline
• Introduction
• Objectives
• Gallablader disease and surgical management
• Surgical magement of Biliary stone and tumor
• Surgical management of biliary injury
• conclusion
 objectives
At the end of session we should be able to
.discrebe anatomy of biliary tree/system
. explain different surgical option on managing
biliary diseases .
 Biliary Tract
Part of the digestive
system.
Made up of:
•Intra hepatic ducts
•Extra hepatic ducts
•Gallbladder
•Common Bile Duct
 —Normal biliary anatomy.

Mortelé K J , Ros P R AJR 2001;177:389-394

©2001 by American Roentgen Ray Society

 Common diseases of biliary tree/biliary
system
• Gallstones

• Biliary tract tumours

• Other conditions
– Acute acalculous cholecystitis
– Mirizzi’s syndrome
– Primary Biliary Cirrhosis
– Primary Sclerosing Cholangitis
– Biliary tract cysts

• Biliary strictures
ERCP and MRCP
 Gallstones and its complication
• In the gallbladder
– Biliary colic
– Acute and chronic cholecystitis
– Empyema
– Mucocoele
– Carcinoma
• In the bile ducts
– Obstructive jaundice
– Pancreatitis
– Cholangitis
• In the Gut
-Bourverete syndrome
– Gallstone ileus
 Surgical management
Patient with indication for surgeries
Cholecystectomy lap vs open followed by
intraoperative cholangiography and CBD exploration.

• Patient who are not fit for operation

Surgical drainage procedure may be employed for
controling infection ,Percutaneous cholecytostomy.
 Cont..
• In a Cochrane review lap cholecystectomy vs. open
cholecystectomy,
• laparoscopic surgery was similar to the open procedure in
complication rates and surgical time. but has a shorter
hospital stay and shorter convalescence.
• The rate of conversions to laparotomy for acute cholecystitis,
from 6% to 35%, risk of conversion to open cholecystectomy
include male sex, age 60 years or older, previous upper
abdominal surgery, thickened gallbladder wall on
ultrasonography.
 Cont…..
• natural orifice transluminal endoscopic surgery, In the case of
cholecystectomy, the most common access is transvaginal

• Merinzzi syndrome
Cholecytectomy or hepatico jejunostomy >II

• Gall bladder empyema

Cholecytectomy or percutaneous cholecystostomy
 Cont..
• Chronic cholecytitis Cholecystectomy
• Bourveret syndrome (duodenum) GOO or
gallstone illeus (terminal illeum) IO
 CHOLEDOCHOLITHIASIS
• preoperative endoscopic retrograde cholangiopancreatography (ERCP)
• If is not feasible (surgically altered anatomy such as Roux-en-Y gastric
bypass), or fails). Surgical biliary surgery is advocated.

• Open/laparoscopic common bile duct exploration (LCBDE) via

transcystic /transductal.

• ERCP followed by LC became a widely accepted method but associated

with postoperative complication .
• LCBDE as a minimally invasive alternative to ERCP have the advantage
of shorter hospital stays and lower cost
• LCBDE can be performed via transcystic /approach or choledochotomy
with T-tube drainage or primary duct closure.
• Transcystic stone retrieval
• Stone retrieval can be accomplished with either
• a biliary balloon (Fogarty) catheter
• a wire basket guided fluoroscopically,
• by transcystic choledochoscope-guided basket
retrieval.
• The choice depends on available expertise and
equipment.
 Cont….
• three bile duct closure methods
1. T-tube insertion,
2.antegrade stenting,
3.primary choledochorrhaphy
• with a bile leakage rate of 3.8% in T-tube insertion,
8.6% in antegrade stenting and 16.7% in primary
choledochorrhaphy, respectively .
Surgical management of biliary stricture
The endoscopic treatment of benign biliary strictures
(BBS) has become widely used in the last decade.
Postoperative biliary injuries, postcholecystectomy,
stricture from primary sclerosing cholangitis (PSC)
common bile duct (CBD) strictures due to chronic
pancreatitis can all be treated endoscobiliary
strictures occurring after liver transplantation.
Stent placement , plastic stent or self expandable metal
stent
Ballooning,
 Cont….
• Hepaticojejunostomy
• choledochoduodenostomy
• hepaticoduodenostomy.
 Biliary injury
• Common bile duct injuries represent a serious and
challenging surgical complication. These complex
injuries are most often a consequence of
laparoscopic cholecystectomy (LC). Proper
management requires a skilled and experienced
hepatobiliary surgical tea Laparoscopic
cholecystectomInitially, the laparoscopic approach
was associated with an almost tenfold increase in
the incidence of bile duct injury compared with
open cholecystectomy
• Complete transection of the common bile duct is the
most frequent biliary injury and the most challenging to
manage.
• This "classic" injury occurs when the common bile duct
is mistaken for the cystic duct, resulting in clipping and
division of the common duct ,
• The injury is often compounded by excision of a
segment of common duct and division of the common
hepatic duct. Despite this sequence of events, biliary
injury is recognized at the time of laparoscopic
cholecystectomy (LC) in a minority of cases.
 Factor contributing biliary injury.
• Contributing factors to bile duct injury include
inflammation in the triangle of Calot,
• a short cystic duct,
• excessive cephalad retraction on the gallbladder fundus,
• insufficient or excessive lateral retraction of the
gallbladder infundibulum .
• use of an end-viewing scope,
• excessive use of cautery.
• surgeon inexperience
• aberrant biliary anatomy can play a role in these injuries
• Role of intraoperative
cholangiography — Intraoperative
cholangiography (IOC) can be used to define
biliary anatomy. There is ongoing debate
about whether routine IOC would help
prevent bile duct injuries during laparoscopic
cholecystectomy .
CLASSIFICATION OF BILIARY INJURIEST
• Strasberg and Bismuth classifications of biliary injury
are based upon the degree and level of injury This
classification is widely used and is
• RECOGNITION OF BILE DUCT INJURY
• bile duct injury recognized during cholecystectomy can
avoid the development of complications.
• Approximately one-third of cases are recognized at the
time of laparoscopic cholecystectomy (LC) when
sudden unexpected bile leakage is noted or a "second"
cystic duct is encountered during the dissection.
Biliary injuries
When to postpone bile duct repair
This may be due to a very proximal injury,
• very small bile ducts, associated inflammation,
• the technical limitations of the surgeon
 Repair of biliary injury
• is to restore flow as to prevents cholangitis, sludge, or
stone formation; restricture, at end stage, biliary cirrhosis.
This goal is best accomplished with a tension-free
anastomosis between healthy tissues.
• A number of surgical alternatives exist for the repair of bile
duct injuries,
• end-to-end repair, Roux-en-Y hepaticojejunostomy or
choledochojejunostomy, and choledochoduodenostomy.
• The choice of repair depends on a number of factors,
including the extent and location of the injury, the
experience of the surgeon, and the timing of the repair.
 Segmental or accessory duct injury
• If a segmental or accessory duct less than 3 mm
has been injured, and cholangiography
demonstrates segmental or subsegmental drainage
by the injured ductal system,
• simple ligation of the injured duct and placement
of a drain is adequate.
• However, if the injured duct is 4 mm or larger, it is
likely to drain multiple hepatic segments or the
entire left or right lobe and therefore requires
operative repa
 Choledochotomy
bile duct injury is sometimes recognized during the
performance of an intraoperative cholangiogram
Recognition usually occurs after the placement of a single
clip across the bile duct, with the introduction of a
cholangiocatheter via a small choledochotomy. In most
situations, the clip should be removed and small
choledochotomy closed with a single 4-0 or 5-0
absorbable suture.
T-tube may be necessary if the choledochotomy is large. In
either case, a closed suction drain should be placed in
the area to control any postoperative bile leak.
 Transection of common bile duct
• —The most common injury involves the
complete transection of the common bile duct
or the common hepatic duct. The aims of any
repair should be to maintain ductal length and
not sacrifice tissue as well as to create a repair
that will not result in postoperative bile
leakage. To accomplish these goals, all repairs
at the time of initial operation should include
external drainage.
 Short injured segment or distal injury
• — If an injured segment of bile duct is short (<1 cm) and the two
ends can be opposed without tension, an end-to-end anastomosis
can be performed with placement of a T-tube through a separate
choledochotomy either above or below the anastomosis (figure 3).
This approach is seldom used as it is associated with a high risk of
stricture formation. Because the injured edges will need
debridement before anastomosis, there are few cases where there
will be sufficient healthy duct tissue to allow end-to-end
anastomosis, and, accordingly, the long-term success rate for this
technique is poor [19]. In the majority of cases, a
hepaticojejunostomy represents the best choice for repair.
Biliary malignancy
 perihilar
• extended right or left hemihepatectomy,
involving half of the liver, the inferior part of
segment IV or V, most of the caudate lobe, the
hilar plate, the extrahepatic bile duct, and
regional lymphadenectomy, is regarded as the
standard radical operation for perihilar CCA
Even for patients with Bismuth and Corlette
types I or II
extended hemihepatectomy is warranted to
ensure negative margins and improve survival
among patients suitable for surgery.
 Distal cca
• Pancreaticoduodenectomy (PD) with regional
lymphadenectomy is the standard
• treatment for distal CCA. Pylorus preservation
does not affect survival outcomes for
• Covered SEMS have become increasingly used
and have demonstrated decreased rates of
occlusion and therefore longer stent patency
(Table 1). In addition to stent occlusion,
another common complication of biliary
stents is stent migration, which is more
frequently seen with plastic and covered
metal stents as opposed to uncovered SEMS.
• bilio-enteric anastomosis in the form of
Roux-en-Y Hepaticojejunostomy or
choledochojejunostomy are considered as
procedures of choice.