Bile Duct Injuries Classification and Management

Introduction to Bile Duct Injuries

The Strasberg-Bismuth classification is a widely used system for categorizing bile duct injuries that occur during laparoscopic cholecystectomy, helping guide management decisions and predict outcomes 1, 4
Type B injuries involve complete occlusion of part of the biliary tree, typically an aberrant right hepatic duct that has been divided and excluded from the main biliary drainage system, and will appear normal on ERCP 1, 3

Type A injuries are characterized by bile leak from minor ducts still in continuity with the common bile duct, such as the cystic duct stump or small ducts in the liver bed 2, 5
Type C injuries involve bile leak from a duct that is not in communication with the main duct system 5, 6
Type D injuries are lateral injuries to the extrahepatic bile ducts without complete transection 2, 6
Type E injuries are circumferential injuries to major bile ducts, subdivided according to the Bismuth classification (E1-E5) based on the level of injury 1, 3

Patients with Type B injuries may present with persistent bile leak or segmental liver atrophy due to biliary obstruction despite a normal-appearing ERCP 1, 2
Additional imaging modalities such as Magnetic Resonance Cholangiopancreatography (MRCP), Percutaneous Transhepatic Cholangiography (PTC), or CT scan may be necessary to identify the isolated occluded segment 3, 6

Type B injuries often require surgical intervention, unlike Type A injuries that may be managed with endoscopic techniques 1, 7
If the occluded segment is small, conservative management may be possible as the affected liver segment may atrophy over time 2, 3
For larger segments, surgical reconstruction with hepaticojejunostomy may be necessary to prevent progressive liver damage 8