Isolated injury to the extrahepatic biliary tract and the gallbladder may occur from a thoracoabdominal injury or an iatrogenic trauma.
This article considers both blunt trauma and penetrating trauma to the extrahepatic biliary tract and the gallbladder. This article also covers the impact of laparoscopic cholecystectomy, which has led to an increasing incidence of bile duct injury.
Typically, a mechanism of crushing or shear injury to the right upper quadrant causes biliary disruption leading to bile peritonitis. The retroduodenal region of the superior portion of the pancreas is the most common site of biliary transection following blunt trauma. The average delay until diagnosis is reportedly 9 days and ranges from hours to 9 months. A perforation or an avulsion of the gallbladder from a blunt thoracoabdominal trauma is extremely rare; penetrating abdominal trauma is a more frequent cause of gallbladder injuries.
Although the exact incidence of nonoperative biliary trauma is unknown, isolated biliary injury without trauma to associated intra-abdominal structures is extremely rare. Fewer than 40 cases of common bile duct avulsion following blunt trauma are reported; however, it is much more rare than penetrating trauma and more difficult to diagnose.
Mortality depends directly on the delay in the diagnosis and the treatment, as well as on the severity of the injury.
Patients with lesions that are promptly discovered and appropriately treated within hours of injury have a mortality rate of less than 10%, while patients with extensive injuries and delayed treatment may have a mortality rate nearing 40%.
Most of the morbidity associated with the extrahepatic biliary tract is related to bile leak and vascular injuries within the hepatoduodenal ligament (hepatic artery/portal vein).
No sexual predilection exists.
Biliary trauma can occur at any age.
Suspect extrahepatic biliary tract trauma when the patient presents with a mechanism of injury consistent with the application of significant blunt force to the thoracoabdominal region. Mechanisms of injury can range from motor vehicle crashes to short falls.
Penetrating trauma to the extrahepatic biliary tract may be obvious based on the external trajectory of the object, especially in stab wounds. In gunshot wounds to the abdomen, which may have a varied intra-abdominal trajectory, the path of injury may be less obvious.
A patient’s history of laparoscopic cholecystectomy is an important consideration in defining an extrahepatic biliary tract injury caused by a prior procedure.
Signs of trauma to the extrahepatic biliary tract caused by thoracoabdominal injury are as follows:
Early signs of biliary leakage may be difficult to appreciate on physical examination.
Hypovolemic shock can occur from intense chemical peritonitis when diagnosis is delayed. This can be followed by septic shock from bacterial overgrowth within a period of hours to days; however, with minimal biliary leakage, shock may not occur and abdominal signs may be absent.
Jaundice is usually observed 3-5 days after injury, along with the passage of clay-colored stools and dark-colored urine.
Increasing abdominal girth accompanied by signs of dehydration and low-grade sepsis may be observed during the first week after trauma.
Direct observation with laparoscopy or laparotomy is used to aid in diagnosing penetrating extrahepatic biliary trauma.
The hepatoduodenal ligament may show contusion, edema, fresh clot formation, or active bleeding.
Signs of trauma to the extrahepatic biliary tract caused by operative laparoscopy are as follows:
Diagnosis of extrahepatic biliary tract trauma may be made during laparoscopy by direct observation of copious amounts of biliary drainage emanating from the porta hepatis or, if suspected, by contrast leak during an intraoperative cholangiogram.
Extrahepatic biliary trauma may also be determined by patient complaints of abdominal pain, nausea, or increasing abdominal discomfort, occurring during the first week after laparoscopic cholecystectomy.
Jaundice may also be present.
Blunt trauma mechanisms (eg, motor vehicle deceleration injuries, falls, assaults)
Penetrating injuries caused by a simple direct force (eg, knife wound) or by a complex, indirect injury (eg, gunshot wound)
Causes of laparoscopic injury to the extrahepatic biliary tract
Direct trauma by grasping forceps
Excessive use of electrocautery and dissection around the porta hepatis, causing tearing of the common bile duct wall or ischemia with resultant stricture formation
Transection of the common bile duct or the right hepatic duct by not identifying the “critical view” during the cystic duct dissection
Improper placement of clips, lacerating the extrahepatic biliary tract
Endoscopic stenting of the biliary tree, increasing the incidence of iatrogenic injuries