Bile duct injury in laparoscopic cholecystectomy: a clinical practice review on prevention, recognition, and management

Common bile duct injury (BDI) remains one of the most serious complications of cholecystectomy, particularly in the laparoscopic era. Although relatively uncommon, BDI carries substantial morbidity, can necessitate complex reconstructive surgery, and may lead to long-term sequelae including biliary stricture, recurrent cholangitis, secondary biliary cirrhosis, and impaired quality of life (QoL). Misidentification of biliary anatomy is the predominant mechanism of injury, often compounded by acute inflammation, dense adhesions, anatomic variation, or difficult operative conditions. Prevention relies on meticulous surgical technique, consistent attainment of the critical view of safety, and selective use of adjuncts such as intraoperative cholangiography or indocyanine green fluorescence imaging to enhance anatomic clarification. Early recognition is crucial and may be suggested by unexpected bile leakage, aberrant ductal anatomy, or division of more than one tubular structure within the hepatocystic triangle. Management strategies are dictated by the type and extent of injury as well as the timing of diagnosis and available surgical expertise. Minor injuries may be managed with primary repair and/or endoscopic or percutaneous interventions, whereas major ductal transections typically require biliary reconstruction, most commonly with Roux-en-Y hepaticojejunostomy. When specialized hepatopancreatobiliary expertise is unavailable, prompt drainage, stabilization, and early referral to a tertiary center are essential. This review summarizes the mechanisms, prevention strategies, intraoperative recognition, and management principles of BDI to support optimal surgical decision-making and improve patient outcomes. Future efforts should focus on standardized classification, management, and reporting of BDI, development of multicenter longitudinal outcome studies, and evaluation of emerging intraoperative technologies to further reduce injury rates and enhance long-term QoL after reconstruction.