Could you specify what you mean “early detected”?

Detected in the course of surgery.

I believe that in very experience hands it can be attempted. However, if transfer to a specialist HPB unit can be arranged shortly, it should be considered as the first option.

Immediate recognition is the best scenario and primary repair is preferred option. However it largely depends on the surgeon’s experience. The problem is that dealing with this complication of one of the simplest operations in abdominal surgery frequently requires expertise gained in major HPB surgery. So if you an expert the possible solutions are clear. If you do not feel confident, first ask immediately for an advice more experienced colleague. If there is any doubt on the possibilities to safely resolve the problem on site – just put drains and refer patient to tertiary center. The patient safety is on highest priority.

Dear collegues, Thanks for answers, however what do you think about performed T-tube drainage in index operation before refer to superior center?

I think it should be considered mainly if the patient cannot undergo a major repair.

I would be concerned about the possibility of increased risk of strictures and therefore the decision should be take into account the long-term plan for the patient.

Dear Dr. Akkapulu,

T-tube is a safe option. On the other hand if and when the patient is reoperated for reconstruction T-tube is used as a guide to localize very fast the point of bile duct injury.

In my country there's just a few specialist in biliary tract surgery, so we usually HAVE to repair the damage ourself. And I agree, T-tube is usually the best choice if is placed under the defect not below it.

First of all we must classify the injury according to Strasburg classification: Type A, B, C, D, E

Only 25-33% of injuries are recognized intraopratively in such cases quicker the repair, the better the outcome!

Immediate managment

1. T-tube placement for minor lacerations

2.Primary duct- to-duct repair only if tension free anastomosis available

3.Biliojejunal anastomosis for major excisional injuries

In retarded diagnosed cases the patient presents with vague abdominal pain, nausea, vomiting, jaundice, fever

Required Investigations

1.US &CT ( ductal dilatation and intrabdominal collection)

2. Cholangiogram

A: ERCP-biliary anatomy and assess the extension of the injury

B:PTC- defines biliary anatomy proximal to injury

C MR angiography - assesses concomitant vascular injuries

MRCP-can miss minor injuries

Treatment strategy

In the presence of biliary peritonitis is not recommended immediate biliary reconstruction.

In such case reconstruction of the biliary tree is best performed electively after an interval of at least 6-8 weeks.

Detection and primary repair are the key to success.As mentioned byDr Paschalis classify the injury.minor and partial injuries in a territiory care centre like ours we perform on table ERCP and stenting.Of course subcoastal drain is a must.In complete transection Roux loop End to Side H-J using 4'0 sutures interrupted, preferably with a stent gives excellent results.If it is a thermal injury we refresh the margins and do a high anastamosis,inspite of it we had stenosis/strictures.If the faclities are not available adviceable to put a drain and refer them to a centre.These ducts are undilated and T-tube placement causes further damage.In acute case on the table MRI is not feasble.

Surgical experience and available facilities in the hospital become the important factors however prevention of BD injuries needs to be reemphasised as the morbitiy of a BD injury can be crippling hence kindly keep threshold to convert low especially in smaller hospitals while doing LC

1)If one is not sure about how to handle, call for help by expert

2)If help is available ;

2a)If the infrastructure is comfortable for the expert (infrastructure, team and instruments), will go ahead in the same place. He would decide what is best in the given scenario.

2b)If the expert is not comfortable, shift to nearby place wherever he / she is comfortable , everything follows as per his advise. Further procedure will be decided and done by him

3)If expert help is not available, send the video clip to expert, seek opinion whether any further step needs to be done before shifting, like suturing, putting drain etc.

4)Not possible to get connected to expert , take step to minimise the peritoneal contamination by simple method like just placing a adequate sized tube drain

(28F) without causing further damage contamination (even placing T tube may cause further damage in some situations) and shift to the place with medical staff accompanying , where proper job is done.

Identifying the injury and not attending properly becomes a major problem.

To err is human, seeking help is divine, half hearted attempt by inexperienced have high failure / stricture rate ,may not only pose problem but may one in trouble.

Patients immediate recovery and getting discharged should not be the only goal , his long term quality of life should be the main goal. This will be appreciated and valued high by every one.