Iatrogenic Bile Duct Injury Research Articles

Intragallbladder versus intravenous indocyanine green (ICG) injection for enhanced bile duct visualization by fluorescent cholangiography during laparoscopic cholecystectomy: a retrospective cohort study.

Iatrogenic bile duct injuries (BDIs) prevention during laparoscopic cholecystectomy (LC) relies on meticulous anatomical dissections through direct visualization. Near-infrared fluorescence (NIRF) with indocyanine green (ICG) improves the visualization of extrahepatic biliary structures. Although ICG can be administered either intravenously or intragallbladder, there remains uncertainty regarding the optimal method for different patient populations. This study sought to assess the suitability of each method for specific patient groups. Between October 2021 and May 2022, 59 consecutive patients underwent fluorescence-guided LC at West China Hospital of Sichuan University. Among them, 32 patients received an intravenous injection of ICG (10 mg) 10 to 12 hours prior to surgery (Group A: the intravenous group), while 27 patients received an intragallbladder injection of ICG (10 mg) (Group B: the intragallbladder group). Baseline clinical factors, inclusion criteria, and measurements of parameters and complications were assessed. Data were retrospectively collected and analyzed to evaluate the comparability of the two groups and the clinical outcomes. Groups A and B included 32 patients (18 males, 14 females), and 27 patients (13 men, 14 women), respectively. In our statistical analysis, significant differences were observed in preoperative diagnoses between the two groups (P=0.041), but the majority of other baseline clinical factors were comparable. Notably, no statistically significant differences were found in complication rates. However, Group A had a shorter operative time (60.38±9.35 vs. 66.78±9.88 min, P=0.01) and superior bile duct fluorescence (P=0.04) than Group B. Interestingly, fluorescence was not observed in impacted gallbladder stones in Group B. Additionally, patients with cirrhosis (P=0.008) and fatty liver (P=0.005) in Group B had higher common bile duct-to-liver ratios (BLRs) than those in Group A. ICG fluorescence cholangiography allows to visualize extrahepatic biliary anatomical structures with both administration methods. However, the efficacy of bile duct fluorescence varies with different administration routes in diverse patient populations. Hence, appropriate administration route selection for ICG should be tailored to individual patients.

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis.

Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.

Is conversion the only itinerary to peace with "hostile" laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) remains the most common surgical procedure worldwide. With these unequivocal benefits, it is today the optimal standard of care for symptomatic cholelithiasis. However, this routine operation can also represent one of the most "hostile" situations. In scenarios of uncertain Critical View of Safety display, total cholecystectomy and laparoscopic approach incur a risk of serious complications such as iatrogenic bile duct injury (IBDI). In such situations, it is necessary to improvise an approach different from the traditional concepts used for elective cases and provide a rescue plan that promotes safety. Although the balance between maintaining LC and moving to an exit procedure is resolved, it remains a challenge for providers to navigate the best alternative strategy. The truth in this debate of seeking optimal results is that surgeons are inclined to resort to conversion, as the most usual itinerary. However, it is inconsistent to consider that the simple fact of switching to an open procedure necessarily protects against IBDI, as well as to approve the conversion as a single manifest alternative to cope without knowing the other saviors procedures and their profiles. Therefore, we found it very useful to compile research data regarding "hostile" CL bailout methods to optimize their use in our practice and to answer the question which strategy to choose? And why?

Shoeshine maneuver for cystic duct dissection: a simple technique to make Calot-triangle dissection smooth.

Laparoscopic cholecystectomy, introduced in 1985 by Prof. Dr. Erich Mühe, has become the gold standard for treating chronic symptomatic calculous cholecystopathy and acute cholecystitis, with an estimated 750,000 procedures performed annually in the United States of America. The risk of iatrogenic bile duct injury persists, ranging from 0.2 to 1.3%. Risk factors include male gender, obesity, acute cholecystitis, previous hepatobiliary surgery, and anatomical variations in Calot's triangle. Strategies to mitigate bile duct injury include the Critical View of Safety and fundus-first dissection, along with intraoperative cholangiography and alternative approaches like subtotal cholecystectomy. This paper introduces the shoeshine technique, a maneuver designed to achieve atraumatic exposure of anatomical structures, local hemostatic control, and ease of infundibulum mobilization. This technique involves the use of a blunt dissection tool and gauze to create traction and enhance visibility in Calot's triangle, particularly beneficial in cases of severe inflammation. Steps include using the critical view of safety and Rouviere's sulcus line for orientation, followed by careful dissection and traction with gauze to maintain stability and reduce the risk of instrument slippage. The technique, routinely used by the authors in over 2000 cases, has shown to enhance patient safety and reduce bile duct injury risks. The shoeshine technique represents a simple and easy way to apply maneuver that can help surgeon during laparoscopic cholecystectomies exposing the hepatocystic area and promote blunt dissection.

Four-Year Report of Iatrogenic Bile Duct Injury Repair from a Referral Hepatobiliary Center.

Iatrogenic bile duct injury (BDI) is one of the most common complications that challenge surgeons performing laparoscopic cholecystectomy (LC). As the number of LC surgeries increases, a pattern of BDI is emerging, but little is known about this matter. The purpose of this study was to assess the pattern of post-LC BDIs directed in a referral center in Iran. Post-BDI patients referred to a hepatobiliary center were studied. Demographic data, clinical status, diagnostic examinations, referral time, post-referral management, and morbidity were analyzed. Nine out of 68 patients had Charcot's cholangitis triad featuring right upper quadrant abdominal pain, fever, and icter. Fever, icter, and itching were the most frequent symptoms. Increased bilirubin, leukocytosis, and abnormal liver function test (LFT) were the most common laboratory abnormalities. 30 patients experienced hepatic artery injury. Out of them, six patients experienced hepatectomy due to hepatic ischemia. Two patients were re-admitted and re-operated, and four patients died. Early and correct treatment by a hepatobiliary surgeon experienced in the management of these types of injuries prevents further complications in patients suffering from iatrogenic BDI. Postoperative complications of bile duct repair, such as anastomosis stricture, are possible; thus, patients need long-term and thorough postoperative observation.

Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy.

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.

Subtotal cholecystectomy as an approach to preventing injury in the left-sided gallbladder in the emergency surgery setting: A case study

A left-sided gallbladder is an unusual anatomic variation that makes gallbladder surgery challenging. Two systematic reviews on surgery for left-sided gallbladder highlighted high iatrogenic bile duct injury rates of 4.4% and 7.3%. This paper reports a female in her 40s with symptoms of acute calculous cholecystitis admitted to a secondary health-care center. After inserting four ports through standard sites for conventional gallbladder surgery, laparoscopic inspection revealed a phlegmonous left-sided gallbladder. No discordant situs of abdominal viscera was noted. Laparoscopic surgery was converted to open subtotal closed-tract cholecystectomy. No post-operative complications related to the surgical site were observed. A left-sided gallbladder affected by severe inflammation and infection is an extraordinary condition that should be considered as a risk factor. If an inflamed left-sided gallbladder is encountered, emergency subtotal cholecystectomy is an alternative to total cholecystectomy when the circumstances to adopt the strategies of a culture of safety in cholecystectomy for complete removal of the gallbladder are unfavorable. Relevance for Patients: Subtotal cholecystectomy in patients with left-sided gallbladder reduces the risk for bile duct injuries, outweighing the potential side effects stemming from this surgical approach.

Economic impact of iatrogenic bile duct injury: a cost analysis

Economic impact of iatrogenic bile duct injury: a cost analysis

Iatrogenic Bile Duct Injury after Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography Stenting Failure: A Case Report and Considerations

Bile duct injuries (BDI) have an incidence that could reach 0.1- 0.3% during open and laparoscopic cholecystectomy, respectively. Nevertheless, they can cause severe complications that could substantially impact the patient’s quality of life. At worst, all these conditions can evolve into septic shock and finally to the patient’s death..

Post-cholecystectomy iatrogenic bile duct injuries: Emerging role for endoscopic management.

Post-cholecystectomy iatrogenic bile duct injuries (IBDIs), are not uncommon and although the frequency of IBDIs vary across the literature, the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy. These injuries caries a great burden on the patients, physicians and the health care systems and sometime are life-threatening. IBDIs are associated with different manifestations that are not limited to abdominal pain, bile leaks from the surgical drains, peritonitis with fever and sometimes jaundice. Such injuries if not witnessed during the surgery, can be diagnosed by combining clinical manifestations, biochemical tests and imaging techniques. Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate. Surgical approach was the ideal approach for such cases, however the introduction of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was a paradigm shift in the management of such injuries due to accepted success rates, lower cost and lower rates of associated morbidity and mortality. However, the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs. ERCP management of IBDIs can be tailored according to the nature of the underlying injury. For the subgroup of patients with complete bile duct ligation and lost ductal continuity, transfer to surgery is indicated without delay. Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP. For low-flow leaks e.g. gallbladder bed leaks, conservative management for 1-2 wk prior to ERCP is advised, in contrary to high-flow leaks e.g. cystic duct leaks and stricture lesions in whom early ERCP is encouraged. Sphincterotomy plus stenting is the ideal management line for cases of IBDIs. Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy. Future studies will solve many unsolved issues in the management of IBDIs.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3±0.5; the MELD score was 9±4.1; the Child-Pugh score was 6±1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272min, and the average blood loss amounted to 79mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4days, with a readmission rate of 15% within 30days. During an average follow-up period of 33months, one patient had to undergo a revision at 18months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Presentation Of Post Cholecystectomy Bile Duct Injuries In A Tertiary Care Hospital

Introduction:The occurrence of iatrogenic bile duct injuries is few, however potentially linked to life-threatening complications, particularly following the advent of laparoscopic cholecystectomy. Aims &Objectives: To evaluate the presentation of post-cholecystectomy bile duct injuries in a tertiary care hospital. Place and Duration of Study: This study was done in the Department of General Surgery at Combined Military Hospital Rawalpindi from Nov 2020 to Dec 2021. Material &Methods: This cross-sectional study was conducted on 15 subjects with post-cholecystectomy bile duct injuries.All the patients who presented to the emergency department and outdoor were included in the study and had post-cholecystectomy CBD injuries. Laparoscopic and open BDI were classified according to Strasberg classification. In descriptive statistics, mean, and standard deviation was used, and in qualitative analysis, frequency and percentages were calculated with the help of the SPSS 23 version, a p-value of? 0.05 was considered significant. Results: In our study, 5 (33.3 %) males and 10 (66.7 %) were females, with a mean age of 47.27 ± 4.79. The presentation on the admission of patients was as follows, 3 (20.0 %) patients had biloma, 4 (26.7 %) had jaundice, 2 (13.3 %) had abdominal pain, 1 (6.7 %) had external biliary fistula, 3 (20.0 %) had Biliary peritonitis and 2 (13.3 %) had a fever. Conclusion: The most common consequence of cholecystectomy was complete resolution, but bile leak and major duct damage cause considerable morbidity, death, and healthcare expenditures. Better outcome was achieved when a nonprimary and skilled hepatobiliary surgeon repaired severe bile duct damage.

How to avoid iatrogenic injuries of the biliary tract in urgent surgery? The use of indocianine green is an alternative.

Iatrogenic bile duct injury is a rare complication, although feared due to its morbidity and mortality. In urgent surgeries, its incidence can be doubled, so in selected cases we must assess the use of resources such as indocyanine green to minimize the risk of biliary or arterial lesions by allowing the correct identification of the structures. We present the case of a 57-year-old patient with acute cholecystitis who underwent laparoscopic cholecystectomy. Given the difficulty in differentiating structures in Calot's triangle, the decision was made to use indocyanine green, which identifies a very short cystic duct, thus avoiding iatrogenic bile duct injury.

The comparison between endoscopic and surgical treatment of delayed iatrogenic bile duct injury by propensity score matching

Objective: To compare the safety and clinical efficacy of endoscopic and surgical treatment of patients with delayed iatrogenic bile duct injury (DBDI) with severity (SG) grade 1 to 2. Methods: The clinical data of 129 patients with SG grade 1 to 2 DBDI who received endoscopic or surgical treatment in the First Hospital of Lanzhou University from November 2007 to November 2021 were retrospectively collected. There were 46 males and 83 females,aged (M(IQR)) 54(22)years(range: 21 to 82 years). The baseline data of the two groups were matched 1∶1 by propensity score matching(caliper value was 0.2). Independent sample t test,rank sum test,χ2 test or Fisher exact probability test were used to analyze the data of the two matched groups. Results: There were 48 patients in each of the endoscopic treatment and surgical groups after matching,and there was no difference in general information between the two groups(both P>0.05). The bile duct injury-repair interval and intraoperative anesthesia complications were not statistically significant between the two groups after matching(all P>0.05). Compared with the surgical group, patients in the endoscopic treatment group had significantly shorter operative time(50 (30) minutes vs. 185 (100) minutes, Z=7.675,P<0.01) and postoperative hospital stay(5 (5) days vs. 12 (7) days, Z=5.848, P<0.01).For safety,there was no statistical difference in the incidence of immediate postoperative complications between the two groups with Clavien-Dindo classification of surgical complications<Ⅲ;the incidence of serious postoperative complications (Clavien-Dindo classification of surgical complications≥Ⅲ) was significantly higher in the surgical group than in the endoscopic treatment group(P=0.012). The incidence of long-term postoperative complications was not statistically different between the two groups(28.1% vs. 20.7%,P=0.562). In terms of efficacy,the postoperative liver function indexes of patients in both groups improved significantly compared with the preoperative period and returned to normal or near normal levels; the postoperative infection indexes of both groups showed an increasing trend,but were within the normal range. Of the 96 patients in both groups,61 obtained follow-up,and the follow-up time was (89.4±48.0)months(range: 3 to 165 months),and there was no statistical difference between the two groups(P=0.079). The probability of excellent long-term follow-up (78.1% vs. 86.2%) was not statistically different between the two groups(P=0.412).In patients with Strasberg-Bismuth type E1,the probability of excellent long-term follow-up was higher in the endoscopic treatment group compared with the surgical group(13/14 vs. 2/5,P=0.037). Conclusions: For DBDI patients with SG grade 1 to 2 and bile duct continuity,endoscopy can be used as the first deterministic treatment. The advantages of endoscopic therapy compared to surgery are the lower incidence of postoperative serious complications,and the shorter duration of surgery and postoperative hospital stay.

Management of Iatrogenic Bile Duct Injuries Following Cholecystectomy

Management of Iatrogenic Bile Duct Injuries Following Cholecystectomy

Bile Duct Reconstruction after Failed Laparoscopic Cholecystectomy: Literature Review

Today, the incidence of iatrogenic bile duct injury in laparoscopic cholecystectomy averages 0.4 % worldwide. In Russia, it accounted for 0.6 % in 2020. Side-to-side hepaticojejunostomy is the operation of choice with complete injury of the common bile duct. It is considered the safest operation, which preserves blood supply, provides wider anastomosis, ensures complete rehabilitation in 75–98 % of cases. Even in the centers of hepatobiliary surgery, the development of strictures after hepaticojejunostomy with traditional access after iatrogenic injury to the bile ducts occurs in 10–20 % of cases. Bile leakage develops in 3.0–3.3 % of cases. The success of reconstructive surgery largely depends on the precision technique of performing anastomosis, which can be ensured mainly by the quality of imaging. The possibility of laparoscopic hepaticojejunostomy after a common bile duct injury is currently a subject of debate, and only few publications report on its successful performance. Most surgeons prefer open anastomosis due to insufficient space for laparoscopic instruments. Although the advantages of laparoscopic surgery over traditional interventions are essential for this category of patients no less than for the others. Robotic laparoscopic surgery with its additional space for instruments in the complete absence of tremor, a twenty-fold increase in three-dimensional image, which increases the accuracy of tissue dissection and the precision of anastomotic sutures, can be an excellent option for working on thin tubular structures in the porta hepatis.

Optimizing surgical management of iatrogenic bile duct injury: transhepatic percutaneous cholangial drainage combined with end-to-end biliary anastomosis.

Iatrogenic bile duct injury remains the most severe complication of gallbladder surgeries. To reduce post-operation complication, we introduce an improved approach for bile duct injury repairment, named transhepatic percutaneous cholangial drainage (TPCD) which combined with end-to-end biliary anastomosis. Clinical data obtained from 12 patients between February 2012 and May 2022 were retrospectively analyzed. Patient demographic, clinical, operative, and follow-up data were analyzed using descriptive statistics. All injuries were repaired successfully and no fatal cases occurred. The mean operative time and hospital stay duration were 367.5 ± 103.2min and 11.3 ± 3.5days, respectively. In two cases (16.7%), bile leakage occurred at the bile duct anastomosis site. Three patients (25.0%) developed low-grade fever and one patient (8.3%) developed a postoperative infection of the incision site. No postoperative bleeding or bile duct strictures occurred in any of the cases. The patients were followed up from 12 to 122months (median, 70.5months). No cholangitis or bile duct restenosis was observed after biliary drainage tube removal. There were no long-term bile duct-related complications seen in the follow-up time. It is safe and feasible for TPCD combined with end-to-end biliary anastomosis using in bile duct injury.

BILE: A Literature Review Based Novel Clinical Classification and Treatment Algorithm of Iatrogenic Bile Duct Injuries.

The management of patients with iatrogenic bile duct injuries (IBDI) is a challenging field, often with dismal medico legal projections. Attempts to classify IBDI have been made repeatedly and the final results were either analytical and extensive but not useful in everyday clinical practice systems, or simple and user friendly but with limited clinical correspondence approaches. The purpose of the present review is to propose a novel, clinical classification system of IBDI by reviewing the relevant literature. A systematic literature review was conducted by performing bibliographic searches in the available electronic databases, including PubMed, Scopus, and the Cochrane Library. Based on the literature results, we propose a five (5) stage (A, B, C, D and E) classification system for IBDI (BILE Classification). Each stage is correlated with the recommended and most appropriate treatment. Although the proposed classification scheme is clinically oriented, the anatomical correspondence of each IBDI stage has been incorporated as well, using the Strasberg classification. BILE classification represents a novel, simple, and dynamic in nature classification system of IBDI. The proposed classification focuses on the clinical consequences of IBDI and provides an action map that can appropriately guide the treatment plan.

Iatrogenic bile duct injury: a stitch in time

Intraoperative bile duct injuries often are difficult to be identified intraoperatively can lead to a variety of complications and require complex surgical procedures for their definitive treatment. With multiple complicated treatment options, these injuries become a therapeutic challenge. We present a case of a 49-year-old lady diagnosed with symptomatic gallstone disease who underwent open cholecystectomy in an outside hospital, during which she had an iatrogenic bile duct injury which was diagnosed postoperatively. She was promptly referred to a higher centre. After investigations, the patient underwent a Roux-en-Y hepaticojejunostomy with a subhepatic drain. The patient was discharged post-successful recovery on post-op day 7. Iatrogenic bile duct injury can be missed intraoperatively in a cholecystectomy. The patient provides non-specific symptoms, and a high degree of suspicion can help in early diagnosis. Prompt treatment by an experienced hepatobiliary surgeon is necessary for the successful treatment of the condition.