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INJURY TO THE BILIARY TRACT - Coggle Diagram
INJURY TO THE BILIARY TRACT
Gallbladder
• Treatment
o The treatment of choice is cholecystectomy.
o Applicable regardless of the etiology of gallbladder injury.
• Prognosis
o The prognosis is typically good.
o Depends on the extent of related injury.
Damage to nearby organs is not uncommon
• Incidence and Etiology of Injury
o Injuries to the gallbladder itself are uncommon.
o Can occur in the setting of penetrating trauma:
Gunshot or stab wounds.
o Can occur in the setting of medical procedures:
Liver biopsy or surgery.
o Nonpenetrating trauma is extremely rare but can cause:
Contusion.
Avulsion.
Laceration.
Rupture.
Traumatic cholecystitis.
Extrahepatic Bile Ducts
• Incidence During Cholecystectomy
o Incidence is estimated to be relatively low (about 0.2%).
o Initial experience with laparoscopic cholecystectomy appeared to show a higher rate compared to the open approach.
o These trends appear to be disappearing as laparoscopic technology and familiarity with the techniques have improved.
• Factors Associated with Injury During Laparoscopic Cholecystectomy
o Acute or chronic inflammation.
o Obesity.
o Anatomic variations.
o Surgical technique.
Inadequate exposure.
Failure to correctly identify structures before ligating or dividing them
Specific Technical Errors:
Excessive cephalad retraction of the gallbladder:
May align the cystic duct with the common bile duct.The latter may then be mistakenly clipped and divided.
Careless use of electrocautery leading to thermal injury.
Dissection deep into the liver parenchyma causing injury to intrahepatic ducts.
Poor clip placement close to the hilar area or to structures not well visualized can result in a clip across a bile duct.
• Etiology of Injury
o Penetrating trauma is rare.
Usually associated with trauma to other viscera.
o The vast majority of injuries are iatrogenic.
Usually occurring during cholecystectomy.
These injuries are among the most feared and litigated complications in surgery.
Can result in significant morbidity.
o Can also occur during other procedures:
Common bile duct exploration.
Division or mobilization of the duodenum during gastrectomy.
Dissection of the hepatic hilum during liver resections.
• Techniques to Avoid Injury
o Use of an Angled Laparoscope (30∘ or 45∘):
Helps visualize anatomic structures, particularly around the triangle of Calot.
Aids in the proper placement of clips.
o Routine Use of Intraoperative Cholangiography (IOC):
Remains controversial as a method to prevent injury.55
The frequency of bile duct injuries is cut by 50% when an IOC is performed.
Critical to successful use is accurate interpretation of the imaging:
Check that the whole biliary system fills with contrast.
Includes both major ducts on the right and the left hepatic duct.
Ensure there is no extravasation of contrast.
o Obtaining the Critical View of Safety (CVS):
Routine use may reduce or limit the extent of injury, or help identify it early, but it does not seem to prevent it entirely.76
No consensus recommendation exists on the use of selective versus routine cholangiography.
The most universally agreed upon method for mitigating risk.
Requires:54
The hepatocystic triangle is dissected free of fat and fibrous tissue.
The lower third of the gallbladder is separated from the cystic plate.
There are two and only two structures running into the gallbladder (the cystic duct, and the cystic artery). (see Fig. 32-23).
o Newer Technologies:
Fluorescence cholangiography to help identify biliary anatomy intraoperatively.
Have shown promising early results, though large-scale applications remain to be seen.77