Biliary Trauma Treatment & Management

Updated: Jun 09, 2017
  • Author: Frederick Merrill Karrer, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Treatment

Surgical Care

Blunt extrahepatic biliary tract injury

See the list below:

  • Perform complete medial reflection of the duodenum (Kocher maneuver) to explore the retroperitoneal biliary system and to identify the injury.
  • Choledochoduodenostomy or choledochojejunostomy are currently the preferred methods of treatment.
  • Simple peribiliary drainage is not recommended because of the high biliary stricture and mortality rates. However, temporary drain placement may be indicated in the multiply-injured patient in order to expedite damage control laparotomy.

Penetrating extrahepatic biliary tract injury

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  • Perform exploratory surgery on patients with significant penetrating abdominal trauma. If the patient is coagulopathic, hypothermic, and acidotic, perform damage control with 4-quadrant packing and intensive care unit resuscitation. [6]
  • Acutely control hepatoduodenal hemorrhage by compression of the hepatoduodenal ligament (Pringle maneuver).
  • After proximal and distal control of the hepatoduodenal ligament is obtained, dissect apart the bile duct, the portal vein, and the hepatic artery to identify injury to each structure.
  • If the bile duct is completely transected, perform a biliary-enteric anastomosis (eg, Roux-en-Y choledochojejunostomy) in a stable patient. Temporary closed suction drain placement may be indicated if a patient is unstable or the triad of coagulopathy, acidosis and hypothermia are present. If the duct is partially transected, then primary repair may be possible; a T-tube may be required in such instances.
  • If the patient cannot tolerate a lengthy operative procedure, a T-tube bridge between the ends of the defect may be possible; however, to avoid the sequelae of recurrent biliary strictures, perform definite repair at a later date. Anastomosis between the gallbladder and a loop of the small intestine with ligation of the proximal and distal ends of the injured common bile duct may be more expeditious.

Laparoscopic extrahepatic biliary tract injury (2 categories)

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  • Minor ductal injuries are those that have intact ductal anatomy without associated strictures (eg, tangential holes in the sidewall of the bile duct from ischemic injury, thermal injury, excessive stripping of the common duct wall). Sphincterotomy and stenting are helpful in controlling the biliary fistula; however, operative reconstruction is necessary if a stricture later develops.
  • Major ductal injuries to the common bile duct occur when large segments of the duct are excised, severely destroyed, or occluded by clips. Practically all of these injuries require formal operative repair.

Gallbladder injury

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  • Cholecystectomy is the best treatment of most injuries of the gallbladder regardless of the mechanism of injury.
  • When injury of other organs or hemodynamic instability precludes cholecystectomy, perform cholecystostomy. This usually requires the placement of drains around the subhepatic space. The cholecystostomy tube can be removed after one month, providing a cholangiogram shows normal biliary flow.
  • Primary suture repair of the gallbladder is not recommended because of the high likelihood of bile leakage. [7]
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Consultations

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  • Ensure that a surgeon or a trauma specialist has primary responsibility for the care of all patients with biliary trauma caused by traumatic mechanisms.
  • Ensure that a surgeon qualified in general surgical, endoscopic, and laparoscopic techniques is involved in the care of patients with operative and iatrogenic injury to the extrahepatic biliary tract.
  • Transfer of a patient with a suspected extrahepatic biliary injury secondary to laparoscopic cholecystectomy to a hepatobiliary specialist has been shown to be the preferred management option with overall better results after definitive operative management.
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Diet

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  • Patients with a complex postoperative course may be fed by a transpyloric feeding tube that is placed intraoperatively.
  • Patients may resume a regular diet after postoperative ileus has resolved.
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Activity

No activity restrictions are required for isolated extrahepatic bile duct system injuries.

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