Repair of common bile duct injuries

INTRODUCTION — 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 team.

This topic will focus on the surgical repair of common bile duct injuries. Details of LC techniques and the endoscopic management of complications from LC are discussed elsewhere.

●(See "Laparoscopic cholecystectomy".)

●(See "Complications of laparoscopic cholecystectomy".)

●(See "Endoscopic management of postcholecystectomy biliary complications".)

INCIDENCE — Laparoscopic cholecystectomy, since its introduction in the early 1990s, has become the "gold standard" for patients with symptomatic gallbladder disease. Initially, the laparoscopic approach was associated with an almost tenfold increase in the incidence of bile duct injury compared with open cholecystectomy [1]. Subsequently, the incidence of bile duct injury over the past 20 years has decreased as surgeons gained more experience with laparoscopic surgery [2], such that the contemporary incidence of bile duct injury with laparoscopic cholecystectomy now approaches the low incidence of bile duct injury previously reported for open cholecystectomy [3].

Two large administrative databases from New York and California reviewing a combined 850,000 laparoscopic cholecystectomies performed between 2005 and 2014 reported an overall incidence of bile duct injuries between 0.1 to 0.2 percent [4,5]. Still, even at these lower rates, with close to one million cholecystectomies performed annually in the United States, these injuries remain a significant cause of patient morbidity; disruption of quality of life; large financial burdens, including malpractice costs; and even mortality (rare).

Efforts to promote safe cholecystectomy have been made, which have culminated in publication of multisociety practice guidelines and a consensus conference on eliminating bile duct injury during cholecystectomy [6].

MECHANISM OF INJURY — Complete transection of the common bile duct is the most frequent biliary injury and the most challenging to manage [1,2]. This "classic" injury occurs when the common bile duct is mistaken for the cystic duct, resulting in clipping and division of the common bile duct (figure 1) [7]. The injury is often compounded by excision of a segment of common bile 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.

Contributing factors to bile duct injury include inflammation in the triangle of Calot, a short cystic duct, excessive cephalad retraction on the gallbladder fundus, and insufficient or excessive lateral retraction of the gallbladder infundibulum [3].

Whether the timing of cholecystectomy in patients with acute cholecystitis increases the risk for bile duct injury is discussed in detail elsewhere. (See "Treatment of acute calculous cholecystitis", section on 'Timing of cholecystectomy'.)

Additionally, use of an end-viewing scope, excessive use of cautery, surgeon inexperience, and aberrant biliary anatomy can play a role in these injuries. (See "Complications of laparoscopic cholecystectomy".)

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 LC [6,8].

Some have maintained that routine IOC is technically challenging, adds cost and time to the procedure, and is unnecessary for the majority of patients [9]. These surgeons selectively use preoperative imaging with magnetic resonance cholangiopancreatography (MRCP) and consider therapeutic endoscopic retrograde cholangiopancreatography (ERCP) when common bile duct stones are identified. Many surgeons perform IOC selectively based on abnormal liver function tests or a dilated common bile duct on preoperative ultrasound. This opinion seems to be well accepted as a survey of general surgeons in the United States demonstrated that only 27 percent use IOC routinely [10]. Others feel strongly that IOC should be performed routinely as part of all LCs so that the operative team is familiar with the procedure [8,11,12]. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

The evidence as to whether IOC protects against bile duct injury is mixed. A retrospective population-based study showed that IOC has a significant protective effect for bile duct injury [13]. The rate of injury was 2.1 per 1000 when IOC was performed routinely during LC and 4.3 per 1000 when IOC was not done. The difference was more striking when the cases were complex rather than routine; the rate of injury was 2.2 per 1000 when IOC was performed and 16.9 per 1000 when IOC was not done.

On the other hand, a retrospective cohort study of 92,932 patients undergoing cholecystectomy from all Medicare claims from the state of Texas during the period of 2000 through 2009 found an overall incidence of common bile duct injury of 0.3 percent [14]. There was no statistically significant association between IOC and common bile duct injury, leading the authors to conclude that IOC is not effective as a preventive strategy against common bile duct injury during cholecystectomy.

Several smaller studies have addressed this question prospectively:

●In a prospective study of 303 patients undergoing LC, 148 had IOC performed routinely and 155 had selective IOC [15]. There was no significant difference in the mean operating time, retained common bile duct stones, or common bile duct injury.

●A prospective study of 1241 patients undergoing LC showed that routine IOC was feasible in 92 percent of cases, and anatomic variations that influenced operative management were found in 13 percent of cases [16]. There were no complications from the IOC, but there were four bile duct injuries despite the use of IOC.

Taken together, these data suggest that IOC can be performed routinely without significant increases in operating room time or complications from the procedure. Routine performance of IOC helps to ensure that the surgical team is familiar with the procedure and that proper equipment is available. If atypical anatomy is encountered during LC, early conversion to an open laparotomy and prompt IOC are recommended. The question as to whether IOC prevents bile duct injury remains unresolved and controversial.

CLASSIFICATION OF BILIARY INJURIES — The Strasberg and Bismuth classifications of biliary injury are based upon the degree and level of injury (figure 2) [3]. This classification is widely used and is discussed in detail elsewhere. (See "Complications of laparoscopic cholecystectomy".)

A retrospective review of 528 patients treated at a major tertiary referral center in the United States found that the majority of postoperative biliary injuries were biliary leaks (ie, Strasberg type A; 239 patients) [17]. Among those with bile duct injuries, Strasberg E1 occurred in 80 patients, Strasberg E2 in 98 patients, Strasberg E3 in 36 patients, Strasberg E4 in 43 patients, and Strasberg E5 in 5 patients.

RECOGNITION OF BILE DUCT INJURY — In many cases, initial appropriate management of a bile duct injury recognized at the time of 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 [3].

Intraoperative diagnosis — If a bile duct injury is observed during LC, repair should be performed only if the surgeon is skilled in these procedures. If not, then transfer to a colleague or another institution is warranted. Laparotomy should not be performed for diagnosis or drainage alone, as this may compound the injury [18]. (See 'When to postpone bile duct repair' below.)

If a biliary injury is recognized and an experienced surgical team is available, then early conversion to an open laparotomy and prompt cholangiography should be performed. Cholangiography will define the proximal anatomy to ensure that all hepatic ducts are accounted for and included in the reconstruction. A study of 88 patients with major bile duct injuries showed that when a cholangiogram was performed and cholangiographic data were complete, the initial repair was successful in 16 of 19 patients (84 percent) [19]. In contrast, repairs of bile duct injuries were unsuccessful in 27 of 28 patients (96 percent) when cholangiograms were not obtained. Additionally, the lack of complete cholangiographic information led to an inappropriate operation in some cases. Details of repair options are discussed below. (See 'Repair options' below.)

When to postpone bile duct repair — In some situations, a surgeon may encounter a bile duct injury but may feel uncomfortable in attempting to repair at the time of the original operation. This may be due to a very proximal injury, very small bile ducts, associated inflammation, or the technical limitations of the surgeon. In this situation, externally draining the biliary system to avoid bile peritonitis and transfer to a tertiary care biliary surgeon without an attempt at repair is the best option.

If possible, a catheter, such as a pediatric feeding tube or cholangiocatheter, should be placed into the proximal transected duct. This catheter can be secured loosely with a suture or clip, but care should be taken not to damage the proximal duct and sacrifice length that may be needed for eventual reconstruction. The catheter is valuable both in controlling the bile leak and allowing access for cholangiography to facilitate placement of percutaneous transhepatic biliary catheters in the postoperative period. In addition, a closed suction drain should be placed dependently in the gallbladder bed to further control the bile leak.

The repair of a bile duct injury is a complicated procedure, and there is clear evidence that the best results are obtained at a center with experienced hepatobiliary surgeons and interventional radiologists [19,20]. In one report, 64 biliary repairs performed by the primary surgeon or surgeons of comparable experiences were compared to 46 repairs performed by biliary surgeons at tertiary referral centers [19]. A successful outcome was obtained in 94 percent of patients whose first repair was by a tertiary care biliary surgeon. In contrast, repair by the original laparoscopic surgeon was successful in only 17 percent of patients, and in no case was a second or third repair by the primary surgeon successful. In a systematic review and meta-analysis of 32 studies, early repair, as opposed to repair delayed for six or more weeks, was associated with higher rates of failure (odds radio [OR] 4.03), more postoperative complications (OR 2.18), and more biliary strictures (OR 6.23), while early referral was associated with lower rates of failure (OR 0.28) and fewer postoperative complications (OR 0.24) than delayed referral [21].

The decision to transfer to a more experienced surgeon is considered good judgment and not "abandonment." The patient and family should be carefully educated and advised about the reasoning for this decision.

Delayed presentation — Most patients with a major bile duct injury are not recognized at the original LC but rather in the early postoperative period with symptoms of fever, abdominal pain, peritonitis, or obstructive jaundice. The initial management of a patient who presents in a delayed fashion following a bile duct injury during LC depends on the nature of the injury and the mode and timing of the presentation. The diagnostic workup and management of these patients is discussed in detail elsewhere. (See "Complications of laparoscopic cholecystectomy".)

Bile leak — If a patient presents early following cholecystectomy, the most common mode of presentation will be a bile leak. If a bile leak is not controlled, this will result in a loculated collection, abscess formation, biliary ascites, or bile peritonitis. If surgical exploration and an attempt at repair are performed in the presence of bile peritonitis due to an uncontrolled bile leak, the dissection in the right upper quadrant will be very difficult, and identification of the decompressed retracted biliary system may be impossible, especially in the hands of the inexperienced biliary surgeon. Biliary reconstruction under these circumstances is technically difficult and, if accomplished at all, will frequently lead to long-term failure in the form of recurrent leak or biliary stricture.

Every attempt should be made to define the biliary anatomy using percutaneous cholangiography and to drain and control the bile leak with percutaneous biliary stents and percutaneous intra-abdominal drains. Repair is then ideally performed six to eight weeks after control of the leak and after intra-abdominal sepsis is resolved and there is less intra-abdominal inflammation. (See "Complications of laparoscopic cholecystectomy" and "Percutaneous transhepatic cholangiography in adults" and "Endoscopic management of postcholecystectomy biliary complications".)

Biliary obstruction — In patients who present with cholangitis from biliary obstruction, defining the anatomy with either endoscopic or percutaneous cholangiography and biliary drainage is important to control sepsis associated with cholangitis before planning elective repair (see "Percutaneous transhepatic cholangiography in adults"). In patients with jaundice, but without sepsis, magnetic resonance cholangiopancreatography (MRCP) can define the anatomy. In cases with favorable anatomy, operative repair without preoperative biliary drainage is an option.

The clinical and radiologic evaluation of a bile leak or obstruction is discussed in detail elsewhere. (See "Complications of laparoscopic cholecystectomy".)

GOAL OF OPERATIVE MANAGEMENT — The goal of operative management of a bile duct injury is the establishment of bile flow into the proximal gastrointestinal tract in a manner that prevents cholangitis, sludge, or stone formation; restricture; or, 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, including 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.

REPAIR OPTIONS — A number of options are available for bile duct repair [22]. The choice depends on the type and extent of injury:

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 repair.

Choledochotomy — A bile duct injury is sometimes recognized during the performance of an intraoperative cholangiogram (image 1). 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. A 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.

The natural history of simple clip application across the bile duct is not defined, but it is unlikely that a late bile duct stricture would develop. If such a stricture does develop, the option of endoscopic management with balloon dilatation and stenting is available and is usually associated with an excellent outcome. (See "Endoscopic management of postcholecystectomy biliary complications".)

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 the 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.

Advantages of the end-to-end anastomosis are that it is less complex and allows endoscopic transampullary cholangiography and stenting to treat any late stricture. If a Roux limb is created and a stricture develops, percutaneous access will be necessary in most cases. Some groups have reported acceptable outcomes with end-to-end anastomosis. One retrospective study reported fewer early postoperative complications in 45 patients treated with end-to-end anastomosis than in 49 patients who underwent hepaticojejunostomy [23]. Long-term results of both surgical approaches were comparable. There were no significant differences in stricture formation, general health status, or quality of life between the two groups.

If this approach is chosen, a Kocher maneuver can be used to help. The Kocher maneuver mobilizes the duodenum from the retroperitoneum by dividing the lateral peritoneal attachments of the duodenum and rotating the duodenum anteromedially to allow inspection of the duodenum, pancreas, and other retroperitoneal structures (figure 4) [24].

Regardless of the choice of reconstruction, the surgeon should always consider getting an experienced colleague to help with both the intraoperative decision making and reconstruction, if available.

Long injured segment or proximal injury — For proximal injuries or if the injured segment of bile duct is greater than 1 cm in length, an end-to-end bile duct anastomosis should be avoided because of the excessive tension that usually exists in these situations. In these circumstances, the distal bile duct should be oversewn, and the proximal bile duct should be debrided of injured tissue and anastomosed in an end-to-side fashion to a Roux-en-Y jejunal limb. The use of a Roux-en-Y jejunal limb is preferable to an anastomosis to the duodenum because in the latter case an anastomotic leak can result in a duodenal fistula. A stent can be placed through the choledochojejunostomy in a retrograde fashion and brought out through the hepatic parenchyma, as illustrated in the figures (figure 5 and figure 6). In addition, a closed suction drain should be placed in the area of the anastomosis to control any postoperative bile leak.

The details of reconstruction vary depending upon the particular anatomic features of the injury or stricture:

Type E1 (Bismuth I) — For injuries with over 2 cm of healthy common hepatic duct preserved, a simple end-to-side biliary enteric anastomosis to a Roux limb will suffice.

Type E2 and E3 (Bismuth II and III) — For injuries in which less than 2 cm of healthy hepatic duct is preserved (Bismuth II) or that involve the bifurcation of the hepatic ducts, but in which the right and left ducts communicate (Bismuth III), the hilar plate of the liver may need to be lowered and the dochotomy extended along a short length of the right or left hepatic duct to allow a common biliary enteric anastomosis.

Type E4 (Bismuth IV) — Injuries that completely separate the right and left systems (Bismuth IV) require separate right and left biliary enteric anastomoses. In rare cases, suitable duct length outside the hepatic parenchyma cannot be obtained, and these cases necessitate isolation of the intrahepatic biliary system. Intraoperative ultrasound may be necessary in these situations.

The right duct can be located as it courses superficially at the inferior margin of the liver and isolated. The parenchyma is excised over the duct, and the duct is opened along its length for 2 cm. A side-to-side biliary enteric anastomosis to a Roux limb is then created.

Similarly, the segment III duct can be isolated on the medial anterior surface of segment III, just lateral to the insertion of the falciform ligament. This duct is located deep in the liver parenchyma, and a wedge of liver parenchyma must be removed to complete the exposure of the duct.

Type E5 (Bismuth V) — The most common procedure for biliary reconstruction following a type E5 injury is Roux-en-Y hepaticojejunostomy with transanastomotic stents (figure 6).

Operative technique — If biliary stents are in place prior to surgery, these should be advanced by the interventional radiologist across the transected segment of duct into the subhepatic space. If the duct is "completely clipped off," the catheters should be advanced right up to the transected end. This is important as the catheters will help the surgeon identify the transected duct, which is usually retracted to the liver and surrounded by inflammation and adhesions.

The bile duct proximal to the injury is carefully dissected circumferentially in a cephalad direction for a distance not to exceed 5 mm. This process is facilitated by having a biliary catheter extending through the end of the transected duct. The catheter can be identified early and followed back to the transected duct, which facilitates mobilization prior to reconstruction. Excessive proximal dissection of the transected duct should be avoided to prevent vascular compromise of the duct. A radiologic guidewire is then placed in the catheter(s).

A series of Coudé catheters may then be passed over the guidewire, to dilate the system, and then the appropriately sized, soft silastic stents are placed over the guidewires. The silastic stents are 12 to 22 French in size and have multiple side holes along 40 percent of their length. The side holes are left to reside within the intrahepatic biliary tree and the portion of the Roux-en-Y jejunal limb used for the biliary anastomosis. The end of the stent without the side holes exits through the liver parenchyma and is brought out through a stab wound in the upper abdominal wall. The biliary stents decompress the biliary tree in the early postoperative period to minimize the consequences of an anastomotic leak. Stents also allow for postoperative cholangiography to assess the patency of the anastomosis and may help decrease the possibility of stricture at the anastomosis [17,20]. Silastic is soft and nonreactive, which minimizes the possibility of tissue damage and maximizes patient comfort. The multiple side holes help facilitate flushing and prevent obstruction of the biliary flow.

After the stents have been placed, a Roux-en-Y limb is prepared and the anastomosis completed as an end-to-side hepaticojejunostomy. The anastomosis is usually done with interrupted 4-0 or 5-0 absorbable sutures.

Closed suction drains are placed behind the anastomosis. Postoperatively, the silastic stents are left to gravity drainage for three to four days. A postoperative cholangiogram is then performed, and if that study is satisfactory, the stents are internalized (image 2). The length of time that the stents are left in place after surgery is variable and determined by the nature of the injury, the patient's clinical course, and follow-up cholangiography.

OUTCOMES

Morbidity and mortality — The perioperative outcomes of surgical repair for biliary injuries following laparoscopic surgery have been reported in a series of 200 patients [25]. The postoperative mortality was 1.7 percent, and the incidence of postoperative complications was 43 percent. The most common complications were wound infections (8 percent), cholangitis (6 percent), and intra-abdominal abscess (3 percent). Early postoperative cholangiography revealed an anastomotic leak in 5 percent and extravasation of the liver dome-stent site in 10 percent of patients. None of the patients required reoperation. Postoperative radiologic intervention, including percutaneous abscess drainage, was required in nine patients (5 percent), and new stent placement was required in four patients (2 percent). Similar results have been reported in other series [26].

Long-term outcomes — A study of long-term outcomes in 142 patients following surgery for bile duct injuries showed that a successful outcome without the need for long-term biliary stents was ultimately achieved in 98 percent of patients [20]. Patients who failed initial surgical management underwent either surgical revision (one case) or balloon dilatation. Only three patients continued to require long-term biliary stents to prevent symptoms, biliary obstruction, and/or cholangitis.

A retrospective review compared long-term outcomes for endoscopic, surgical, or interventional (radiology) management of postoperative bile duct leaks and injuries in 528 patients [17]. Patients with bile leaks were managed almost exclusively by endoscopists (96 percent) with a 96 percent success rate, defined as no need for further intervention after the initial 12 months of therapy. Overall success rates for bile duct injury were best for surgery (88 percent), followed by endoscopy (76 percent) and interventional radiology (50 percent). Similar to above, the postoperative mortality in the surgical group was 1.9 percent. The overall morbidity was 24 percent with the most common biliary-specific complications, including bile leaks and organ space infection.

In a retrospective study of 120 patients with Strasberg grade A, B, C, or D bile duct injuries, Strasberg grade D injuries were typically managed surgically and resulted in the highest complication rate (40 percent) and treatment cost ($14,252) [27]. Strasberg grade B injuries were most often managed without surgery but led to a similarly high complication rate (25 percent) and treatment cost ($13,689). (See 'Classification of biliary injuries' above.)

Quality of life — Several studies have examined quality of life (QOL) of patients following surgical repair of bile duct injuries, and most demonstrate return of the individual to baseline functional health. One study compared QOL in patients who underwent successful surgical reconstruction of bile duct injury to age-matched individuals who had undergone recent uncomplicated laparoscopic cholecystectomy (LC) and to age-matched healthy controls [28]. The patients who had a successful bile duct reconstruction were not statistically different from the controls in the physical and social domains but did score lower in the psychological domain of the assessment. (See "Evaluation of health-related quality of life (HRQL) in patients with a serious life-threatening illness".)

The pursuit of a lawsuit related to the injury appeared to be a significant factor in influencing the QOL in all domains. An analysis of malpractice claims associated with biliary tract surgery found that bile duct injury accounted for almost 70 percent of claims. Forty percent of claims resulted in patient payout with the median cost per claim being $264,650. The 60 percent of claims not resulting in patient payout averaged over $15,000 in legal and administrative fees [29]. Among the 231 malpractice lawsuits pertaining to cholecystectomy from 2000 to 2018 in the Westlaw database, 1 in 3 reached a plaintiff verdict or settlement, with a median payout of half a million dollars [30].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gallbladder surgery" and "Society guideline links: Biliary complications following surgery".)

SUMMARY AND RECOMMENDATIONS

●Mechanism of injury – Common bile duct injuries represent a serious and challenging surgical complication. These complex injuries are most often a consequence of laparoscopic cholecystectomy. Injury to the common bile duct occurs most commonly when it is mistaken for the cystic duct. Intraoperative cholangiography delineates biliary anatomy and thus may decrease the risk of iatrogenic common bile duct injury. (See 'Mechanism of injury' above.)

●Classification – The Strasberg and Bismuth classifications of biliary injury are based upon the degree and level of injury (figure 1). (See 'Classification of biliary injuries' above.)

●Intraoperative recognition of injury – Approximately one-third of bile duct injuries are recognized at the time of laparoscopic cholecystectomy. If bile leakage or other concerning findings are observed after the completion of the cholecystectomy, the appropriately trained surgeon proceeds with conversion to an open procedure, intraoperative cholangiography, and repair. (See 'Intraoperative diagnosis' above.)

Immediate repair is best not attempted in patients with a very proximal bile duct injury, very small bile ducts, or associated inflammation. Drainage should be established to control the bile leak and prevent bile peritonitis. The patient should be transferred to an appropriate facility if the treating surgeon has limited experience with complex hepatobiliary surgery. (See 'When to postpone bile duct repair' above.)

●Delayed presentation of injury – Most patients with a major bile duct injury are not recognized intraoperatively during laparoscopic cholecystectomy but present in a delayed manner with postoperative fever, abdominal pain, peritonitis indicative of a bile leak, or obstructive jaundice. For patients who present with a postoperative bile leak, percutaneous cholangiography is performed to define the biliary anatomy and the bile leak controlled using percutaneous biliary stents or intra-abdominal drains. Repair is performed six to eight weeks after control of the leak once intra-abdominal sepsis is resolved. (See 'Delayed presentation' above and 'Bile leak' above.)

●Biliary obstruction – For patients who present with biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis associated with cholangitis prior to repair. (See 'Biliary obstruction' above.)

●Goals of operative management – The goal of operative management of a bile duct injury is to reestablish flow of bile into the proximal gastrointestinal tract in a manner that prevents sludge, stone formation, stricture, cholangitis, and biliary cirrhosis. (See 'Goal of operative management' above.)

●Surgical techniques – We suggest end-to-side over end-to-end anastomosis for hepaticojejunostomy as the best option for the repair for most common bile duct injuries (Grade 2C). (See 'Repair options' above.)

●Outcomes – The majority of patients undergoing surgery for bile duct injuries achieve a successful outcome without the need for long-term biliary stents. (See 'Outcomes' above.)