Introduction

Bile duct injury (BDI) during cholecystectomy is a problem with far-reaching medical, economic, and legal implications. It is liable to occur even in experienced hands when one is past the so-called learning curve [1]. All efforts must be made to prevent this complication, as an error on the part of the surgeon can significantly impair the patient’s quality of life (QOL) [2] or even endanger it [3]. Evidence suggests that these injuries are best managed at an experienced hepatobiliary unit for optimal results [4]. Though it is nearly two decades since laparoscopic cholecystectomy (LC) has become established as the gold standard for patients with symptomatic gallstone disease, the incidence of BDI remains higher than with open cholecystectomy (0.2 % to 0.7 % vs. 0.1 % to 0.3 %) [3]. It has been reported that, when compared with open surgery, biliary injuries sustained during LC are more likely to present earlier, more often associated with persistent bile leaks, and usually closer to the porta hepatis [5]. Due to the enormity of the impact of a BDI, it is worthwhile to always endeavor to prevent rather than treat one. Evaluation of a patient with BDI, stratification of the type and extent of injury, and planning the appropriate timing and type of intervention require the input of specialists with special interest in this area for optimal outcome.

Pathogenesis

Risk factors

Risk factors for BDI during cholecystectomy can be thought to occur due to anatomical factors, nature of the pathology, and operator-dependent factors. Of these, only the last is modifiable by adopting safe surgical practices. In cases where the gallbladder is adherent to the common bile duct (CBD) or common hepatic duct (CHD), traditional techniques like the infundibular or fundus-first techniques can become error traps resulting in serious biliovascular injuries [6]. At the beginning of the laparoscopic era, BDI occurred with increasing frequency in the initial part of the learning curve of surgeons who switched from a conventional open approach, with loss of haptic sensation and three-dimensional orientation. In the present day, most surgical trainees learn LC under the supervision of preceptors who have more experience. Although most injuries occur within the surgeon’s first 100 laparoscopic cholecystectomies, one third happen after the surgeon has performed more than 200 cases [7]; it is more than inexperience that leads to BDI [7]. BDI during laparoscopy tends to be more complex by being more proximal and associated with concomitant vascular injury. A classic laparoscopic injury occurs when the CBD is mistaken for the cystic duct and is caused by excessive cephalad retraction of the fundus of the gallbladder in which the cystic and common ducts become closely aligned. The surgeon, erroneously thinking the cystic duct has been successfully divided, continues to dissect the common duct proximally and eventually transects the CHD [8]. The right hepatic artery (RHA) is also typically injured or ligated because of its proximity. It is reported that BDI more often than not occurs due to an error in perception rather than due to a lack of knowledge, skill, or judgment [9]. The cognitive misperception of anatomy is so compelling that injuries are seldom recognized at the time of surgery and the operation may be thought to be normal [9].

Prevention of BDI

Demonstration of the critical view of safety as described by Strasberg et al. [10] identifies the cystic duct and artery as they enter the gallbladder and permits safe clipping and division of these structures. The main reason for inadvertent transection of the CBD is mistaking it to be the cystic duct [9, 11, 12]. Rouveire’s sulcus [13] and Hartmann’s pouch are important landmarks; however, care is taken in cases where the latter is distorted or abolished as in patients with atrophic cholecystitis, impacted cystic duct stone, and adhesions between cystic duct and the neck of gallbladder and in incorrect dissection [14]. The traction on the gallbladder in LC should be in a lateral direction rather than in a superior direction to prevent tenting of the CBD and inadvertent injury during clipping.

Bleeding obscures the operating field and there is no place for panic or blind application of clips or electrocautery. In many instances, pressure for a few minutes will control bleeding and permit accurate hemostasis [15]. In cases of uncontrolled bleeding, conversion to an open procedure is a wise option. Use of a 30° scope permits proper visualization. In some instances of acute cholecystitis, it may be a good idea to open the gallbladder (when one is reasonably sure that there is no malignancy) at a safe area, extract the stones, oversew the cystic duct, and complete the cholecystectomy [16]. A prudent approach in such cases would be to do a cholecystostomy which would entail the least risk [15].

Population-based studies [3] have shown a reduction in risk if surgeons perform routine intraoperative cholangiography, although all are subject to bias. Routine use of cholangiography is cost-effective [17], with maximum efficiency achieved when used by inexperienced surgeons or when complex disease is encountered. Though intraoperative cholangiography does not prevent an injury, it does give the opportunity to identify it early. Archer et al. [7] report that 81 % of bile duct injuries were detected at the time of initial surgery when a cholangiogram was obtained in comparison to only 45 % when it was not employed. This has significant implications for the patient given the improved outcome associated with early appropriate repair.

Surgery should be unhurried, keeping patient safety paramount. Inadvertent injuries of the bile duct are reported to occur due to casual approach, overconfidence, and ignorance of difficult situations [12]. Using analogies from aviation safety, there are excellent expert reviews on methods to prevent BDI during LC [15, 18]. The central tenet of safe surgery is to recognize danger signs well in advance and avoid it. It cannot be emphasized enough that timely conversion to an open procedure is a smart decision rather than a failure [9, 15]. Heightened awareness to the possibility of BDI in every case of cholecystectomy, adoption of safe surgical practices, and knowing when to back out/call for help should be important aspects of resident training. Risk factors for BDI and possible preventive measures are summarized in Table 1.

Table 1 Risk factors and prevention of BDI during cholecystectomy
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Classification

Most classification systems for BDI encountered during laparoscopy describe a spectrum ranging from minor cystic duct leaks to complete transection [10], even excision of the CBD with or without a concomitant vascular injury [19, 20]. Most large series from experienced authors also elucidate the mechanisms of these injuries and preventive strategies [10, 19, 20]. Although classifications are useful for standardization of outcome reporting and guiding management decisions, there is no ideal system. Most current versions fail to take into account important short-term prognostic factors, including mode of presentation, attempts at previous repair, presence of concomitant sepsis, and stability of the patient [21]. Other important issues like concomitant vascular injury, presence of secondary biliary cirrhosis, portal hypertension, and segmental atrophy are also not considered routinely in all systems.

The salient features of most prevailing classification systems are detailed in Table 2 [22–30]. Bismuth proposed a classification system (Fig. 1) based on the lowest level at which healthy biliary mucosa is available for anastomosis [22]. This classification is applicable while evaluating long-term sequelae following BDI. The laparoscopic era has seen reports of complex and high injuries, often accompanied by damage to the RHA. Strasberg’s classification of laparoscopic biliary injuries is stratified from classes A to E [10]. Class E injuries are further subdivided into E1 to E5 according to Bismuth’s classification system.

Table 2 Classification systems for postcholecystectomy BDI
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Fig. 1
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Magnetic resonance images illustrating the different types of postcholecystectomy bile duct strictures as per the Bismuth classification. The arrow in the central figure points to clips applied to the segment 6 duct

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There are numerous other classifications from reputed centers (Table 2). All these grade the extent of the severity of biliary injury and describe varying types of injuries to the extrahepatic bile ducts and the mechanisms responsible for these. Despite the presence of so many classification systems, the Bismuth and Strasberg systems remain most popular and widely used. Till a comprehensive and ideal system becomes widely established, it is important to document BDI descriptively in medical records, both for better understanding of factors that lead to the injury and for medicolegal purposes.

Management

Initial evaluation

Management depends on the timing of recognition of injury, the extent of BDI, the patient’s condition, and the availability of expertise. A high index of suspicion is required to diagnose BDI in the postoperative period as only about 20 % to 30 % of injuries are diagnosed at the time of initial surgery [9]. The aim of evaluation is, firstly, to assess and tackle any acute conditions such as bile collections or ongoing bleeding. The second step is to assess the extent and type of injury to plan the timing and mode of intervention. If the patient has been referred from another hospital, it is useful to review the operating notes and talk to the primary surgeon. The importance of accurate, unhurried, and frank communication with patients and their relatives with clear documentation in medical records cannot be overemphasized. Initial symptoms [31] may be nonspecific; patients are discharged from the hospital frequently only to present a few days later with jaundice, biliary drainage from an existing drain, biliary ascites, or bile peritonitis [9]. Late presentation is in the form of a stricture which is usually diagnosed on imaging with deranged liver function tests (LFT) (elevated bilirubin and alkaline phosphatase) in the face of recurrent bouts of cholangitis. In some instances, patients present with secondary biliary cirrhosis and its complications. Persistent increase in bilirubin or alkaline phosphatase after a couple of days after cholecystectomy should prompt the assessment of a BDI. Abdominal ultrasound (USG) will evaluate the presence of fluid collections and intrahepatic biliary dilatation. A computed tomography (CT) has better sensitivity than USG (96 % vs. 70 %) [31] in detecting fluid collections (Fig. 2) and is useful if the latter is equivocal. If BDI is strongly suspected or image-guided aspiration shows bile, a cholangiogram is indicated. A magnetic resonance cholangiogram (MRC) is usually the investigation of choice. Both a percutaneous transhepatic cholangiogram (PTC) and MRC are comparable with regard to image quality, detection of intrahepatic bile duct dilatation, assessment of the level of injury, and detection of abnormalities such as intraductal calculi, cholangitic liver abscesses, and atrophy of liver lobes. MRC is, however, noninvasive and provides additional information on associated fluid collections and portal hypertension [32]. A percutaneous drain, if placed at the time of surgery, may be used to perform a cholangiogram. If a leak from the cystic duct or bile duct, a lateral injury, or a noncircumferential stricture is apparent on MRC, an endoscopic retrograde cholangiography (ERC) is indicated as it has therapeutic potential. ERC will not be helpful if there is a complete cutoff with no continuity of the extrahepatic biliary tree. While interpreting cholangiograms, it is important to confirm integrity of all sectoral bile ducts [6]. It is easy to miss a sectoral duct injury unless specifically sought for (Fig. 3). There is no role for diagnostic exploratory laparotomy/relaparoscopy to delineate biliary anatomy. Emergency surgery in this setting is done for peritoneal lavage and drainage in order to establish a controlled biliary fistula. Once referred to a specialist unit for management, an assessment of vascular anatomy is required as vascular injury is present in 12 % to 40 % of patients [33]. Vascular assessment is particularly important if there has been a previous attempt at repair and in the management of more proximal injury, which may be associated with damage to the RHA. This is of significance when an early repair is contemplated. It should be remembered that a malignant stricture can very rarely masquerade as a postcholecystectomy benign stricture [34].

Fig. 2
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Coronal section of a computed tomogram depicting diffuse intra-abdominal fluid which turned out to be bile. Clips in the hepatic hilum following laparoscopic cholecystectomy are well seen

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Fig. 3
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The panel on the left side depicts an endoscopic retrograde cholangiogram (ERC) which can be erroneously interpreted as normal. The arrow points to clips applied during LC. The panel on the right side shows a tubogram in the same patient filling the injured right posterior sectoral duct. The bold arrow points to the stent inserted at the time of ERC

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Selection of patients for percutaneous, endoscopic, or surgical management

In the management of postcholecystectomy BDI, interventional radiology, endoscopy, and surgery have complementary rather than competing roles. Before embarking on any mode of intervention, it is important to take stock of the patient’s general condition, the type of injury, and the expected benefits and risks in light of the published results of the procedure. Free bile in the peritoneal cavity should be a high alert situation. It is often seen that different patients react differently to it and a particular patient may throw up an unexpectedly severe systemic response after a quiescent course. Multiple image-guided percutaneous catheters can be used by a skillful interventional radiologist to obtain drainage and establish a controlled external biliary fistula. ERC and stenting can stop an ongoing leak. However, the presence of peritonitis calls for surgical intervention. Where expertise is available, a thorough laparoscopic lavage and drain placement under direct vision can achieve the objective of containing systemic sepsis without the need for a laparotomy. The emphasis is on multidisciplinary management. An algorithm for the management of BDI utilizing different modalities of treatment is depicted in Fig. 4. In class A injuries, ERC and stenting has a 99 % success rate and is clearly the treatment of choice [35]. Class B injuries may remain asymptomatic or present late with atrophy–hypertrophy complex (Fig. 5) and sectoral cholangitis. The latter may require hepatectomy. An isolated sectoral duct injury may present with ongoing biliary leak (class C) despite an ERC interpreted mistakenly as being normal [36]. In this setting, percutaneous drainage of the isolated segment allows proximal control of the biliary leak in many cases [36]. In patients who require surgery, hepaticojejunostomy (HJ) is the treatment of choice [37] and the catheter acts as guide at the time of surgery [38]. For class D injuries without tissue loss, a reasonable surgical option is primary closure with fine absorbable sutures and subhepatic drainage, rather than placement of a T-tube; experience in liver transplantation has shown that a T-tube placed within a choledochocholedochostomy is associated with a significantly higher stricture rate than with repair without a T-tube (25 % vs. 11 %) [39]. In patients with significant loss of duct substance, an HJ is the preferred option, although end-to-end repair may be considered in select cases [40]. Surgical repair is indicated for injuries with complete transection of the bile duct and for most E4 and E5 injuries.

Fig. 4
figure 4

Algorithm depicting management strategies in patients presenting with postcholecystectomy BDI. LFT liver function tests, USG ultrasonography, CT computed tomography, MRI magnetic resonance imaging, HJ hepaticojejunostomy, PTC percutaneous transhepatic cholangiogram. Asterisk represents patients not diagnosed at the time of initial surgery, the preferred initial management strategy in this group

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Fig. 5
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Atrophy–hypertrophy complex, evident on MRI by crowding of right-sided ducts and hypertrophied left-sided ducts

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There is no prospective data on the optimal treatment of biliary injuries that lead to strictures. For major duct injuries without complete transection (class D) or injuries leading to stricture (E1–E4), endoscopic therapy with stenting and traditional surgical HJ are treatment options [41]. In a recent review [33], of 48 such patients selected for endoscopic therapy, successfully cannulated patients received endoscopic sphincterotomy and placement of a single plastic 10-F stent. Endoscopic intervention was suspended in patients who had biliary strictures longer than 2 cm or a lateral wall defect larger than one half the bile duct diameter with a concomitant bile leak. ERCs were repeated every 3 months to change the stents and to evaluate the strictures. Bile duct strictures were dilated by 6- to 8-mm pneumatic balloons and between one and three plastic stents were placed to help maintain duct patency. The average treatment interval for stenting was 12.2 ± 9.8 months. No deaths occurred during the treatment interval. The mean follow up time was 31 ± 24 months. Thirty-six patients had effective stricture resolution. Ten patients (22 %) had symptomatic recurrence after completing the yearlong treatment protocol, with either biliary colic or cholangitis. Four of them ultimately needed surgery. There was no mortality, the morbidity rate was low (8 %), and a good outcome was seen in 91 % of the patients. If the stricture did not resolve after four endoscopic treatments, they were converted to surgical bilioenteric bypasses.

In a recent publication from Mayo Clinic [35] evaluating the merits of endoscopic therapy, seven patients had class D BDI; four were managed surgically and three endoscopically (median duration of stenting was 5 months with good to excellent outcomes). Of 66 patients with E1 to E4 BDI, 44 (67 %) were initially managed surgically and 22 (33 %) endoscopically. Thirteen of the latter 22 underwent sustained endoscopic therapy (median stent time, 7 months), which was successful in 10 (77 %). All four patients with E5 injuries were managed surgically. Median follow up was 45 months. The authors concluded that, although surgical management remains the preferred therapy, short-term endoscopic treatment for E1 to E4 injuries can optimize the patient and operative field for reconstruction. Prolonged stenting in select patients with E1 to E4 injuries characterized by stenosis is successful in the majority. These data suggest that endoscopy is a viable option for the management of BDIs in cases where continuity of duct is maintained proximal and distal to the injury and in patients with strictures amenable to negotiation by the endoscopist [35]. However, they caution that endoscopy requires repeated interventions and frequent follow up which has a bearing on the cost and QOL of patients. Surgical reconstruction by an experienced surgeon at a specialist hepatobiliary center is an effective treatment with immediate relief of symptoms and excellent long-term outcomes [4, 42], even in E3 and E4 strictures. In BDI where the biliary confluence is intact (Strasberg types E1, E2, and select E3 [Sikora type III A]), a high HJ onto the extrahepatic left duct gives excellent results [43]. In E4 and E5 strictures, surgery is invariably the treatment of choice. QOL studies comparing patients with BDI managed surgically to uncomplicated LC patients report similar rates of minor symptomatology and comparable QOL scores in physical, social, and mental health indices [44, 45]. The Mayo Clinic group [35] believes that, although endoscopy has a proven role, it should be entertained in a select population: patients who refuse surgery, are not optimal surgical candidates in whom surgical risks outweigh the benefits, or for those in whom stricture develops after surgical reconstruction. Advances in endoscopic treatment, rendezvous procedures, and use of removable self-expanding metal stents are promising new areas which may extend the benefits of minimally invasive treatment to a select subgroup of patients.

Percutaneous transhepatic dilatation/stenting is an alternative to endoscopic therapy in select class E injuries and is also particularly useful in recurrent strictures after HJ, where endoscopic access is not feasible [46, 47]. In patients with a complete cutoff, percutaneous transhepatic drains are useful as a temporizing measure before surgery in patients with bile leak or cholangitis [48]. They serve as a guide during surgery and can be converted to long-term transanastomotic stents in select cases where the bile duct is thin walled and small in diameter (3–4 mm) [49]. Complications of PTC are not uncommon, occurring in up to 26 % of patients, and include cholangitis, hemobilia, bleeding from hepatic parenchyma or adjacent vessels, pleural violation with pneumothorax, biliopleural fistula, and inadvertent injury to adjacent structures [50]. Multidisciplinary efforts to select appropriate candidates for a particular approach after informed consent seems to be a reasonable option till we have level 1 evidence. This would of course require the cooperation of many high-volume centers to recruit patients with strict inclusion criteria and long-term well-defined follow up data.

Early vs. delayed surgical repair

The timing of repair (early/late) is determined by the general condition of the patient, favorable local abdominal factors for successful repair (absence of sepsis, collections, and inflammation), and expertise of the operating surgeon. It is believed that the first repair when performed by an experienced hepatobiliary surgeon gives the best chance of success. In an oft-quoted early paper [51], only 17 % of repairs were successful in those performed by a nontertiary-level surgeon compared with 94 % of those performed by a specialist, and the hospital stay was three times longer when managed by a nonspecialist surgeon (78 vs. 222 days). The morbidity and mortality of those treated by a nonspecialist compared with specialist was 58 % and 1.6 % vs. 4 % and 0 %, respectively [51]. If expertise is unavailable, transfer of the patient should be considered after adequate drainage is achieved by large-bore drains [49]. As depicted in Fig. 4, the primary care surgeon should achieve damage control by stopping ongoing bleed by at least packing and establishing a controlled biliary fistula using a subhepatic drain. Injudicious attempts at exploration of the bile leak and repair by the primary surgeon may exacerbate the injury [52]. Immediate detection and repair are associated with an improved outcome, and the minimum standard of care after recognition of a BDI is immediate referral to an experienced surgeon [20]. Also, the operative findings should be clearly and accurately documented and communicated at the time of referral. It cannot be overemphasized that the patient and relatives should be made aware of the complication in a frank and lucid manner. The Birmingham group has demonstrated the safety and feasibility of on-table repair of BDI as an outreach service by specialist surgeons with minimal disruption to the patient pathway [53]. Despite reports of good results with a choledocho-hepaticoduodenostomy [54], a Roux-en-Y HJ is the gold standard for the reconstruction of bile ducts injured during cholecystectomy. End-to-end anastomosis can be utilized as a treatment strategy if BDI is detected during surgery, in particular if there is no extensive tissue loss, the local anatomy is clear, and there is no inflammation [55]. Postoperative complications can adequately be managed by endoscopic or percutaneous drainage in majority of the patients. Reconstructive surgery after a complicated end-to-end anastomosis is associated with low morbidity and no mortality.

Factors associated with an improved outcome include the use of absorbable sutures, single-layer anastomosis, and debridement back to healthy noninflamed or scarred tissue [51]. To ensure an adequate length of anastomosis, the left hepatic duct can be exposed along its extrahepatic course (Fig. 6) at the base of segment 4 [22, 56] to perform a Roux-en-Y HJ and obtain wide drainage of the bile duct. For patients with high injuries and disruption of the confluence, Lillemoe et al. [57] have described a technique similar to that used for a left-sided approach. By resecting the base of the gallbladder fossa, the right ducts are exposed to allow separate anastomoses to be fashioned. If the criteria for a successful anastomosis cannot be met, as in the event of disruption of the confluence with an associated vascular injury, significant diathermy injury, or surrounding sepsis, it may be prudent to delay repair and establish a controlled fistula [15]. This allows the final level of the injury to demarcate and inflammation to subside, determines the need for concomitant hepatic resection, and allows the ducts to dilate and mature to improve the likelihood of a successful result [15]. Nutritional status should be optimized with bile refeeding if feasible to maintain intestinal barrier function [58] and overcome fat-soluble vitamin deficiency, particularly in patients receiving enteral nutrition. In the presence of a biliary fistula with stricture, there is no consensus on the optimal duration of waiting before a HJ can be performed. It generally ranges from 3 to 6 months during which time the fistula is likely to close/get controlled without an undue risk of secondary biliary cirrhosis. Delayed repair has shown excellent long-term outcomes with a very low risk of mortality [59]. If the patient’s condition is optimal and the repair is performed at an experienced center, both early and delayed repair have comparable long-term outcomes [60].

Fig. 6
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Intraoperative photograph of the proximal bile duct prepared for a wide anastomosis

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Biliovascular injuries

The pathophysiology of concurrent biliary and vascular injury has been most recently described in detail in a review by Strasberg and Helton [33]. In published series on BDI following LC, concomitant injury of a hepatic artery has been reported in 12 % to 40 % of patients [33, 61, 62]. Of those with damage to the RHA, around 10 % develop hepatic infarction [33]. Elimination of the compensatory collateral flow through marginal arteries and hilar shunt by a high BDI exacerbates the hepatic ischemia when the RHA is occluded [33]. High injuries and vascular injuries are a risk factor for hepatectomy for BDI [63, 64]. In a recent review, Truant et al. [64] found a total of 99 hepatectomies reported among 1,756 (5.6 %) patients referred for postcholecystectomy BDI. Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95 % confidence interval, 8.0–234.2) than patients without complex injury [64]. In contrast, when the hilar arcade is preserved and the ischemic stricture has demarcated, a delayed repair in experienced hands has good outcomes even in the presence of arterial injury. A prospective study of 54 patients, which employed the left duct approach to bile duct repair, showed no difference in outcome between those with and without arterial injury [62]. Hence, unless accompanied with massive hepatic necrosis, RHA injury following cholecystectomy does not adversely affect the outcome of biliary injury if a delayed repair is performed. Vascular injury associated with sepsis is an adverse prognostic factor [65]. Hepatectomy in this setting is associated with high postoperative morbidity (60 %) and even mortality (10 %). Liver transplantation may sometimes be required as a last resort after biliovascular injury [66]. Figure 7 depicts an algorithm for the management of RHA injury associated with BDI.

Fig. 7
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Algorithm depicting management of right hepatic artery injury associated with postcholecystectomy biliary injury

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Secondary biliary cirrhosis and portal hypertension

Secondary biliary cirrhosis after BDI is uncommon, and its incidence varies from 8 % to 20 % in Indian series [60, 67]. This represents the most important cause of portal hypertension in this subgroup of patients. Risk factors include long duration of symptomatic obstruction, especially recurrent cholangitis, and a long interval between cholecystectomy and HJ and previous attempts at repair [60, 67, 68]. Secondary biliary cirrhosis has been reported to occur at 6 months, but has been reported to occur even as early as 20 weeks from the time of BDI [69]. Early fibrosis is reversible with a timely HJ as proven on follow up biopsies [69]. Duration of biliary obstruction, basal alanine aminotransferase (ALT) level, and time to normalization of ALT level after surgical repair have been shown to be independent predictors of advanced hepatic fibrosis [70]. In patients with extensive collaterals in the hilum, it is a good option to stage the HJ with a shunt in the first stage; however, most patients with mild portal hypertension and a patent portal vein, a single-stage HJ can be performed safely with excellent long-term results [67, 71]. For established cirrhosis, liver transplantation is the ultimate option. Figure 8 depicts an algorithm for the surgical management of secondary biliary cirrhosis in the setting of BDI.

Fig. 8
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Algorithm for surgical management of secondary biliary cirrhosis in the setting of postcholecystectomy biliary injury

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Long-term outcome

While evaluating outcomes of therapeutic modalities for biliary injuries, clinical, biochemical, and radiological domains are scored. A popular system is that of McDonald et al. [72] in which grades A and B incorporate asymptomatic patients with normal LFT or mild elevation of LFT, respectively. Grade C includes symptomatic patients with abnormal LFT, while grade D includes patients who require intervention (percutaneous dilatation/surgical revision). The degree of hepatic fibrosis is a very important predictor of abnormal recovery pattern of LFT [73], and Sikora et al. [69] have proposed that this be part of scoring systems to stratify patient outcome. While evaluating the success of an intervention, long-term follow up of at least 5 years is recommended as delayed strictures are reported [74]. While surgical series have shown excellent long-term outcomes both for primary and recurrent strictures [75, 76], contemporary endoscopic series [35, 41, 77] have shown comparable outcomes in a select subset of patients (Table 3). The definitions for the classification of BDI, the type of patients selected for interventions, and the outcome data should be comparable while evaluating surgical and endoscopic treatment. Also, QOL issues are important, considering that patients who undergo LC with a normal course are discharged many a time as day cases, while those with problems are subject to months of morbidity and risk of mortality. QOL after BDI is inadequately studied. The Amsterdam group has reported as early as 2001 that QOL is adversely affected in patients who sustain a BDI despite excellent medical outcomes such as normal LFT and radiology [2]. In a longitudinal study published after 11 years of follow up, the QOL scores did not improve [78]. Moore et al. [79] also noted long-term detrimental effects on health-related QOL in patients with BDI. Only a case–control study by Hogan et al. [80] has demonstrated comparable outcomes in terms of QOL in patients who had a BDI vs. those with uncomplicated cholecystectomy. In these studies, it has been noted that pending litigation claims do influence the way a patient perceives his or her current status and these patients tend to score worse on QOL indices.

Table 3 Long-term outcome after surgical/endoscopic treatment for postcholecystectomy BDI
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Summary and Conclusions

Preventive strategies and safe surgery are of utmost importance to minimize BDI during cholecystectomy. The importance of frank communication with the patient and accurate documentation cannot be overemphasized. Diagnosis requires a high index of suspicion with focused clinical, biochemical, and radiological examination. Widely accepted classification systems include the Bismuth and Strasberg systems. In addition to providing a uniform terminology for accurate documentation and reporting, they also stratify patients based on the complexity of the injury and possible management strategies. Irrespective of the modality of treatment chosen, the initial strategy is to control sepsis and bleeding. ERC stenting is the treatment of choice for class A injuries and has a role to play in select class D injuries without tissue loss. Aberrant hepatic duct injuries without and with a leak (classes B and C) are managed according to the timing and severity of their presentation and can be challenging to diagnose and treat. The gold standard for the treatment of class E injuries is surgery by a Roux-en-Y HJ with data to support long-term excellent outcomes both for early and delayed repairs. ERC/PTC stricture dilatation has a role to play in some of those injuries where there is a partial stricture without complete transection. Combined high biliovascular injuries are associated with a poorer outcome, especially when an associated RHA injury has to be tackled at the time of an early repair by the primary operating surgeon. Long-standing biliary obstruction can lead to secondary biliary cirrhosis with portal hypertension. Liver transplantation is rarely required in BDI due either to acute liver failure following biliovascular injury or refractory secondary biliary cirrhosis with portal hypertension. A multidisciplinary approach-driven management protocol can follow a structured algorithm, tailoring the best available evidence to suit individual patient circumstances.