الفهرس 
Anatomy of the biliary systemOnly 14 pages are availabe for public view
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Abstract
Cholecystectomy is the most frequently performed operation in abdominal surgery. Laparoscopic cholecystectomy replacing open cholecystectomy is now performed in more than 80% of surgically treated patients for symptomatic gall stones.
The complications include intra operative and post operative complications; intra operative complications include hemorrhage, perforation of the gall bladder wall, bile duct injury while post operative complications include bile duct stricture, missed stone(s), bile leakage , perihepatic collection and infection.
Bile duct injuries are the worst and most serious complication of the laparoscopic cholecystectomy, frequency in laparoscopic technique in more than 2% of cases. it has been emphasized that only 10% of cases with bile duct injury are recognized in the first week , but 60-70% developed stricture at a later stage (3-4 months postoperatively or even occur after a year).
Strasberg et al., 2002: have classified laparoscopic bile duct injury into 5 types:
Type A: Bile leakage from minor ducts.
Type B: Occlusion of aberrant right duct
Type C: Transaction of aberrant right hepatic duct.
Type D: Lateral injury to major e bile ducts.
Type E: Circumferential injury to major bile ducts.
The mechanisms involved in bile duct injuries during laparoscopic cholecystectomy identify the basic error groups:
A) Misinterpretation of the anatomy.
B) Technical errors.
Except for type D and type E injuries, intraoperative identification is uncommon. Even in type E injuries, identification during the operation occurs in only 25% of cases. Injuries have been detected as a result of seeing bile or an open duct. At other times, they have been diagnosed cholangiography or after conversion to an open procedure.
Bile leak is the most frequent post operative technical complication of laparoscopic cholecystectomy occurring in 0.2% of patients.
There are several modes of presentation in the postoperative period, but pain with sepsis and jaundice are the two most common. Pain with sepsis tends to occur in injury types associated with biloma types A, C, and D, white understandably jaundice is the most common way that type F injuries present.
Recently, magnetic resonance cholangiopancreatography (MRCP) has emerged as a potentially valuable tool in evaluating proximal bile duct injuries. This non-invasive modality provides sticking images of the biliary tree, and yield anatomical information in a single study that was previously obtainable only with CT and PTC.
Vascular assessment is particularly important if there has been a previous attempt to repair and in the management of more proximal injury, which may be associated with damage to the right hepatic artery.
A multidisciplinary approach (gastroenterologist, radiologist and surgeon) is advocated not only for the diagnostic work-up, but also to decide on the optimal treatment modalities.
There are factors that influence the surgical success rate: preoperative diagnostic evaluation, notably cholangiography, the surgical technique, and the experience of the surgeon.
Bile collections are usually managed by placement of percutaneous intra-abdominal drains under CT or US guidance.
ERCP is the investigation procedure of first choice in the diagnostic assessment of complex post cholecystectomy cases presenting with complications. Retained bile duct stones after cholecystectomy are an established entity. By far the most common etiologic diagnostic finding was residual biliary calculi, followed by complete iatrogenic bile duct obstruction. Endoscopic sphincterotomy and stone retrieval should be the first line treatment for postoperative choledocholithiasis. Diagnosis of post operative complications was successfully obtained in > 90% of cases. ERCP has the potential of saving the patient from exploration of CBD and a repeat surgical procedure with attendant morbidity and mortality.
Another method employed in the treatment of bile duct injuries is balloon dilatation and stenting. The balloon dilatation can be performed either via an endoscopic approach or via a percutaneous transhepatic route for higher strictures or recurrent strictures following a hepaticojejunostomy.
The surgical treatment of bile duct injuries should be separated into treatment of injuries detected during the (laparoscopic) procedure, the early postoperative recognized injury (within a few days after surgery); and finally the delayed detected injuries.
Roux -en-Y hepaticojejunostomy has the best success rate for the repair of a transaction or resection injury of the common bile duct or common hepatic duct. Experienced surgeons report a success rate of 8O- and, in series that include less experienced surgeons; the success rate is 60-70%.
The advantage of an end-to-end repair includes simplicity and preservation of duct length. This advantage is mitigated by the 5O% stricture rate during follow-up, which usually requires operative revision. The standard operative management for biliary strictures is to perform a tension-free, mucosa-to-mucosa biliary-enteric anastomisis.