Curriculum Vitae

Name : Errawan R. Wiradisuria, MD

Birth Place & Date : Bandung (Indonesia), April 2nd, 1957

Present Position : General Surgeon, Consultant in Digestive

and Laparoscopic Surgery

FORMAL EDUCATION

1. General Practitioner : Faculty of Medicine, University of Padjadjaran, Bandung -

Indonesia (March, 23rd, 1983)

2. General Surgeon : Dept. of Surgery, Faculty of Medicine University of

Indonesia/Cipto Mangunkusumo Hospital, Jakarta - Indonesia (Oct., 08th ,1991)

3. Digestive Surgeon : Div. of Digestive Surgery, Dept of Surgery Faculty of

Medicine, University of Indonesia/Cipto Mangunkusumo Hospital, Jakarta –
Indonesia (May, 20th, 1997)

4. Magister of Hospital Management : Faculty of Public Health, University of

Gadjah Mada, Yogyakarta – Indonesia (April, 24th, 2008)
ACTIVITY (IN ENDO-LAPAROSCOPIC SURGERY FIELD)
 July 1997 – now : Member of Endoscopic Laparoscopic Surgeons of Asia (ELSA)
 2002 – now : Executive Council Member (Governor) of ELSA

 1997 – now : Instructor (Faculty Member) in many Laparoscopic Surgery Courses (organized by ISES)
 1998 – now : Member of International Hepato-Pancreato-Biliary Association (IHPBA)
 Aug. 2006 – now : Board Member of Asia Endosurgery Task Force (AETF)

 Oct. 2007 – now : Live Member of Asia Pacific Hernia Society (APHS)
 May 2008 – now : President of Indonesian Society of Endo-Laparoscopic Surgeons (ISES) 2008 – 2012 & 2012 - 2016
 May 2008 – now : Secretary General of Indonesian Hernia Society
 Dec. 2008 – now : Editor member of Asian Journal of Endoscopic Surgery
 Oct. 2009 – now : International Member of SAGES (Society of American Gastrointestinal and Endoscopic Surgeons)
 2010 – now : Chairman Of Advance Laparascopic Surgery Courses (Asia-Pacific), Bali International Training and
Development Center (BITDEC), Tanah Lot, Bali
 Dec 2011 – 2015 : Secretary General of Indonesian Society of Digestive Surgeons (IKABDI)
 March 2012 – now : Member of ASCS (ASEAN Society of Colorectal Surgeons – Indonesian Representative)

 March 8 - 10th, 2012 : Chairman of SAGES Scientific Plennary Session (Laparoscopic Surgery In Solid Organ), San Diego, CA, USA
 March 28th, 2013 : Chairman of AETF Scientific Workshop (Laparoscopic Colorectal Surgery), Fujinomia, Tokyo, Japan)
 April, 2013 : Observer in Department of HBP, MAYO CLINIC, Jacksonville, Florida, USA
 Nov. 2013 – 2015 : Vice President of ELSA (Endoscopic Laparoscopic Surgeons of Asia)
 Oct. 9 - 12th, 2014 : President of The International Congress of ELSA, Bali, Indonesia
 Feb 2016 – now : Vice President of Indonesian Society of Digestive Surgeons (IKABDI)
 April 6 - 9th 2016 : President of The Congress: ASEAN Society of Colo-Rectal Surgeons (ASCS), Bali, Indonesia
 April 8 2016 – now : President of ASEAN Society of Colo-Rectal Surgeons (ASCS): 2016 – 2018
 Dec 2016 – now : Board Member of Asia Pacific Endo-Lap Surgery Group (APELS)
MANAGEMENT OF
CBD INJURY
dr. Errawan Wiradisuria, SpB-KBD, M.Kes
 Background
• Bile Duct Injuries (BDI)
majority caused by iatrogenic,
while accidental traumas only
1–5% of the total number of
biliary injuries
• BDI will impact on the patient´s
quality of life
• Reconstruction & treatment
techniques have been evolving
• BDI required multidisciplinary
approach & the selection of
adequate management will
improve the prognosis
 Bile Duct Injuries

Iatrogenic Traumatic

• occurs during: • occurs during:

 Abdominal surgeries  Penetrating trauma

 Endoscopic procedures  Blunt trauma
(mainly during laparoscopic
cholecystectomy)
 Percutaneus cannulation
Iatrogenic Bile Duct Injury
 1990
Bile duct injury by laparoscopic cholecystectomy 0,3% - 1,3%
(due to learning curve effect)

2015
Bile duct injury by laparoscopic cholecystectomy 0,16% - 0,6%
Bile duct injury by open cholecystectomy 0,2% - 0,3%

* Granados-Romero JJ et al. Int J Res Med Sci. 2016 Mar;4(3):677-684

** Salama IA et al. HPB Surgery. Vol 2014, Article ID 575136
 Risk Factors
• Advanced age
• Male sex (?)
• Anatomic anomalies of bile duct
• Acute cholecystitis compared with chronic cholecystitis
• Anatomical perception errors & technical errors in
laparoscopic surgery

** BDI in laparoscopic surgery are more serious & complex due to the
proximal location & it is often associated with vascular injury

* Granados-Romero JJ et al. Int J Res Med Sci. 2016 Mar;4(3):677-684

 * http://www.gog.net.nz/biliarystricture.html

Variations in the anatomy of the gallbladder & biliary tree

 Mirizzi Syndrome
Type I : extrinsic compression
of the CBD by an impacted
gallstone

Type II: cholecystobiliary

fistula involving 1/3 of the
circumference of the bile duct

Type III: cholecystobiliary

fistula compromises up to 2/3
of the circumference of the bile
duct
* http://www.wjgnet.com/1007-9327/full/v18/i34/4639.htm

Type IV: cholecystobiliary fistula has destroyed the bile duct wall &
comprises the whole circumference of the bile duct

Type V: corresponds to any type of Mirizzi associated with a bilioenteric

fistula with / without gallstone ileus
Technical Errors
• Thermal injury with
excessive or blind application
of electrocautery, laser
dissection, or ultrasonic scalpel

• Excessive dissection of the

common bile duct may cause
local ischemia & structuring

• Injudicious application of
clips to control bleeding can
lead to obstruction of a part of
the biliary tree or the entire
extrahepatic bile duct
* Lahey clinic, Burlington. 1994
Technical Errors

CBD RHD

* ANZ Journal of Surgery. 78(12):1109-14

Excessive lateral traction of the gallbladder can result in ‘tenting’
a) The distal CBD appears to run downwards from the GB, mimicking the
cystic duct
b) Anatomical variation (shadowed) may lead to the right hepatic duct being
perceived as the cystic duct.
 Technical Errors

* 10.1016/j.jamcollsurg.2007.01.038
 Strasberg Classification
 Type A injury - leakage into the gallbladder bed from minor hepatic ducts
or the cystic duct

 Type B (occlusion) & C (transection) injuries - injury to aberrant right

hepatic ducts

 Type D injury - Lateral

damage to the common bile
duct.
 Type E injury - Injury to the
main ducts (E1 – E5 / the
Bismuth classification)

* http://cursoenarm.net/
 Classification of bile duct injury : Bismuth Classification

* Granados-Romero JJ et al. Int J Res Med Sci. 2016 Mar;4(3):677-684

 Stewart-Way
Classification

Class I: CBD is mistaken for the

cystic duct, but the error is
recognized before CBD is divided

Class II: Damage to CHD from clips

/ cautery used too close to the duct.
This often occurs where visibility is
limited due to inflammation /
bleeding * https://synapse.koreamed.org/

Class III: The most common type, CBD is mistaken for the cystic duct. The
CBD is transected & a variable portion including the junction of the cystic &
CBD is excised / removed

Class IV: Damage to the right hepatic duct (RHD), either because this
structure is mistaken for the cystic duct / because it is injured during
dissection
Diagnosis
Intraoperative
• 15 - 30 % of bile duct injuries are diagnosed during surgery
• Abnormal intraoperative cholangiography

Postoperative
Clinical presentation: Laboratorium result:
- Diffuse abdominal pain - Leucocytosis
- Nausea - Mixed hyperbilirubinemia
- Fever
- Impaired intestinal motility
- Bile collections / jaundice
- Peritonitis
 Comparison between sensitivity & specifity in image studies to diagnosis of bile
duct injuries
* Granados-Romero JJ et al. Int J Res Med Sci. 2016 Mar;4(3):677-684
Definitive Management

Re-establishment of bile duct flow into

proximal gastrointestinal tract

Prevent cholangitis, sludge / stone formation,

re-structuring & progressive liver injury
Iatrogenic Bile Duct Injury
Management
Treatment algorithm in case of bile duct
injury according to Strasberg classification

* Martin D, et al. BioScience Trends. 2016; 10(3):197-201

Choices of Treatment
I. Hepaticojejunostomy Roux-en-Y
Hepaticojejunostomy is generally used when
there is total CBD section
1. Careful dissection & division of the middle or
superior part of the extrahepatic bile duct, hilar or
intrahepatic bile duct

2. Basic procedure of the anastomosis

• Two neighboring duct orifices can be joined
by two interrupted stitches to prepare them
for anastomosis as a common channel

* Hirano S, et al. J Hepatobiliary Pancreat Sci. 2012 May; 19(3): 203–209

 I. Hepaticojejunostomy Roux-en-Y

3. Preparation of Roux-en-Y jejunal limb

• Sufficient jejunal limb length  transecting the jejunum
approximately 20 cm distal from the Treitz ligament

4. Preparation of the transanastomotic stent tube

• 5-Fr tubes with knots 3 cm from the tips along with a blunt
needle attached to each end. The same number of tubes as
bile ducts to be reconstructed are inserted from the jejunal
incision & pulled out from the jejunal stump using the blunt
needle

5. Suture of the posterior layer of the anastomosis

• Single-layer interrupted sutures with 4-0 or 5-0
absorbable monofilament material are used for the
anastomosis
• The approximate center of the each stitch is clipped
by a rubber-shod clamp so as to maintain distance
between the jejunum & the bile duct by suspending
them together with forceps clipping the bilateral
ends of the stitch
* Hirano S, et al. J Hepatobiliary Pancreat Sci. 2012 May; 19(3): 203–209
 I. Hepaticojejunostomy Roux-en-Y

6. Insertion & fixation of the transanastomotic

stent
• A stent tube is inserted into a bile duct passing
above the strings of the stent fixation suture,
which form a “V” shaped opening. The fixation
is usually performed on the proximal side of
the bulge of the tube to prevent the tube from
slipping out

7. Sutures of the anterior layer of the anastomosis

• As with the posterior row, suturing should start
at the most dorsal side and progress ventrally

8. Fixation of the stent tube to the jejunal stump

• The tubes are fixed to the jejunal serosal layer with preferable rapid-absorbable
suture, in order to permit removal of the tube within a few weeks. The stump of the
proximal jejunum is anastomosed with the side wall of the Roux-en-Y limb in end-
to-side or side-to-side fashion.

* Hirano S, et al. J Hepatobiliary Pancreat Sci. 2012 May; 19(3): 203–209

Hepaticojejunostomy Roux-en-Y
Hepaticojejunostomy Roux-en-Y
Choices of Treatment
II. Primary suture
• Primary suture should be done only
when there is absolute certainty that
has not been compromised blood
supply to the CBD
• Transection of bile duct < 25% of
ductal circumference

III. T-tube placement

• T-tube placement with open /
laparoscopic repair for small
partial injuries
• Transection of bile duct 25 – 50% of
ductal circumference
Choices of Treatment
IV. Endoscopic retrograde cholangio-
pancreatography (ERCP)
Conditions:
• Lateral duct wall injury / cystic duct leak  trans
ampullary stent controls leak & provides
definitive treatment
• Distal CBD must be intact to augment internal
drainage with endoscopic stent
 Choices of Treatment
V. Percutaneus radiological techniques

Percutaneus Transhepatic Cholangiogram

(PTC) is a less invasive method for
patients who are not good candidates for
surgical procedures but with bilioenteric
continuity injuries.
Choices of Treatment
• In over 90% of patients, the biliary stent placement is an excellent
treatment of the injury
• Biliary stent (metal / plastic tube) inserted by endoscopic retrograde
cholangiopancreatography or percutaneous transhepatic cholangiography
as both being a technic of diagnostic imaging & a therapeutic device

• Absorbable prosthesis have several advantages as a recent method:

 No need to be extracted or impregnated with medication
 Degraded by hydrolysis in the human body & remain intact for at least three
months with evidence of total disintegration the following weeks, which may
prevent a recurrence
 Short placement to avoid chronic inflammatory processes & reduces
complications that arise in traditional techniques
 Preservation of the length of bile duct
Traumatic Bile Duct Injury
• Traumatic biliary injuries are uncommon & frequently associated with
damage to other viscera

• Injuries to the biliary tree are relatively rare, only 1–2% of all cases of
abdominal trauma

• Vast majority due to penetrating trauma

• Eighty-five percent of patients diagnosed with extrahepatic biliary

traumas suffer injuries of the gallbladder, whereas involvement of the
main bile duct alone occurs only in 15% of the cases

• Extrahepatic bile duct injuries < 30% of biliary injuries

• The most frequent location is in the proximity of the hepatic hilum or

within the head of the pancreas
Diagnosis
Traumatic injuries can be grouped into three time periods following the
initial insult:
1. Immediate (< 72 hours)
• Diagnosed during a trauma laparotomy
• The presence of free bile intraoperative
• The presesence of bile in intra-abdominal drain

2. Intermediate (72 hours – 6 weeks)

• Progressive abdominal distension (caused by a large biloma / biliary ascites)
• Vague abdominal pain, nausea, vomiting & occasionally jaundice
• ± 50% patient with bile in the peritoneum have nolocalizing symptoms, but
infected bile show signs of peritonitis

3. Delayed (> 6 weeks)

• Abnormal liver function test
• Obscure jaundice with no obvious cause
Diagnosis
• Most of the intrahepatic bile duct injuries are associated with hepatic
parenchyma damage. The classification often based on the liver injury
scale as proposed by Moore et al
Diagnosis
• Extrahepatic bile duct injuries can affect the biliary bifurcation, the hepatic
duct, the cystic duct, or the common hepatic duct
Traumatic Complication
 Biloma / Biliary ascites
• A loculated collection of bile, generally in the subhepatic space
• Asymptomatic sterile bilomas should be allowed to reabsorb, either
spontaneously or via intervention
• Symptomatic / persistent bilomas can be drained percutaneously under
radiological guidance to facilitate resolution
• Biliary ascites caused by the disruption of a major bile duct
Traumatic Complication
 Biliary stricture
• Disruption of the axial blood
supply  an ischaemic stricture
manifest as painless jaundice 
liver failure

 Fistula
• Occur in approximately 3% of
patients with major hepatic
injuries
• Communicate with intrathoracic
structures (bronchobiliary /
pleurobiliary fistula) or vascular
structures.
• Arterial fistula  haemobilia
(upper GI hemorrhage, right
upper quadrant pain & jaundice)
 Hemobilia
• Hemobilia is extravasation of blood in the biliary tree due to the presence
of a communication between a blood vessel & the bile ducts
• The majority of symptomatic hemobilias are caused by arterial bleed
• The frequency ranges between 3 - 7%

• Symptomatic patients with hemobilia

present with melena (90%), abdominal
pain (70%) & obstructive jaundice (60%)
• Diagnosis of hemobilia can be confirmed by
arterial phase computerized tomography
(CT) or selective hepatic artery
arteriography
• Selective arteriogram by percutaneous
approach has become the leading modality
to treat hemobilia with microembolization
of the arterial branches communicating
with the biliary tree with success rates in
84–95% of patients
Management
• Treatment depends:
• Mechanism of injury
• The stability of the patient
• The location & grade of injury
• The delay in reaching a diagnosis

 Partial transection (< 25% of ductal circumference)  suture repair / T-

tube
 Complete transection / 25 – 50% of ductal circumference:
 Roux-en-Y hepaticojejunostomy
 Simple end-to-end repair (associated with high incidence of stricture formation)

 Intrapancreatic CBD injury  divide the duct at the superior border of

pancreas  ligating the distal portion  perform Roux-en-Y
choledochojejunostomy
 Endoscopic : Surgical

• Success rates 72% 83%

• Complication rates 35% 26%
* Common complication of biliary prothese: cholangitis, pancreatitis, perforation of
the bile duct, occlusion, migration / dislodgement of the prosthesis

Interventional Radiology : Surgical

• Success rates 52% 89%

• Complication rates 35% 25%
* Common complications of transhepatic stenting & percutaneous
dilatation: haemorrhage (haemobilia, bleeding from hepatic parenchyma /
adjacent vessels), bile leakage & cholangitis, pneumothorax (resulting from
pleural transgression) & less commonly, perforation of adjacent structures
(gall bladder & large bowel)
Summary

• Higher incidence rate of bile duct injuries linked with laparoscopic

cholecystectomy can be reduced by proper identification of anatomical
variations & cautious steps to prevent technical errors

• Recognized biliary injury & immediate management intraoperative will

reduce complication rate & excessive cost for other postoperative
treatments

• Postoperative patients with minor biliary injury managed with

conservative treatment, drainage or biliary stent placement by endoscopic
or percutaneous intervention, while major biliary injuries usually treated
by surgical procedure
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