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

Introduction

Cholecystectomy is one of the most commonly performed elective abdominal procedures, with 750,000 to 1 million cases performed in the United States annually (1,2). Intraoperative injury to the common bile duct (CBD) remains one of the most feared complications, particularly in the laparoscopic era. The incidence of bile duct injury (BDI) during laparoscopic cholecystectomy ranges from 0.2–0.6%, 0.7% with robotic cholecystectomy, and 0.2–0.3% with open cholecystectomy (1,3-9). Despite the overall low rate of occurrence, BDI remains a considerable complication given the sheer number of cholecystectomies performed yearly. These injuries can result in significant short and long-term morbidity and mortality, prolonged hospitalization, and reoperation (10). While prevention is paramount, prompt detection of injury and appropriate management are critical (11). Prognosis improves substantially with early recognition, repair by experienced teams, and follow-up to monitor for stricture or complications (12).

The current management of BDI is largely shaped by laparoscopic practice, where misidentification of biliary anatomy remains the predominant mechanism of injury (13,14). Specific challenges of laparoscopic surgery include limited tactile feedback, reliance on optical orientation, and difficulty achieving appropriate exposure in inflamed tissue planes, all of which influence both prevention and intraoperative decision-making (12,13). Management strategies must account for factors such as timely recognition under minimally invasive constraints, appropriate use of intraoperative cholangiography (IOC) or fluorescence guidance, and early adoption of bailout strategies as deliberate safety maneuvers rather than procedural failures (13,15,16).

Although consensus guidelines and prior reviews have addressed prevention and treatment of BDI, important areas of uncertainty persist including the role and use of imaging adjuncts and optimal timing and pathway for repair injuries recognized postoperatively (12,17,18). The goal of this review is to provide a focused framework for the prevention, recognition, classification, and management of BDI during laparoscopic cholecystectomy. By emphasizing areas of ongoing variability and unresolved consensus, this review aims to support optimal surgical decision-making and improve outcomes following one of the most consequential complications of minimally invasive biliary surgery.

Etiology and prevention strategies

The most common mechanism of common BDI is misidentification of the CBD, in particular, mistaking the CBD for the cystic duct (19). Excessive traction superiorly on the gallbladder fundus and/or lack of lateral retraction on the gallbladder infundibulum while exposing the hepatocystic triangle may tent the CBD upward making it vulnerable to clipping or transection (13,20). Significant inflammation, chronic scarring with adhesions, or impacted stones can obscure the anatomy (21,22). Anatomic variation in the CBD and cystic duct can also predispose to injury (23,24).

The critical view of safety (CVS) was first described by Strasberg in 1995 as a technique to minimize BDI during laparoscopic cholecystectomy. CVS entails dissection of the gallbladder to remove all fibrofatty tissue, isolation of only 2 structures entering the gallbladder, and mobilization of at least one third of the gallbladder off the cystic plate (14). Adherence to obtaining the CVS has been shown to significantly reduce the incidence of BDI and is considered the gold standard for safe cholecystectomy (13).

An additional method to assist in the identification and safe transection of the cystic duct is the use of IOC. Through cannulating the cystic duct and injecting contrast, IOC can assist in the detection of CBD stones and the definition of biliary anatomy. Use of IOC intraoperatively for anatomic clarification is supported by current multi-society guidelines and is linked to a decreased incidence of BDI, though the benefit is greatest specifically in patients with acute cholecystitis (6,13). Despite these advantages, routine use of IOC remains variable and is performed in only a minority of cholecystectomies in the United States, with reported utilization rates ranging from approximately 25% to 45% depending on surgeon preference, case complexity, and institutional practice patterns (25,26).

Indocyanine green (ICG) fluorescence is an additional tool surgeons can use for the identification of biliary anatomy. A near-infrared fluorescent dye, ICG is administered intravenously to patients and taken up in hepatocytes. Its excretion directly into bile allows visualization of the biliary tract with the use of near-infrared optics (27,28). Data from a meta-analysis demonstrated a higher rate of visualization and identification of biliary structures with the use of ICG, as well as a lower rate of conversion to open surgery (29-32). It may be particularly useful in obese patients, though its use in the setting of thickened tissue secondary to significant inflammation may be limited due to poor visualization (15). Though contemporary guidelines increasingly recognize ICG as a useful adjunct for biliary visualization, its use is not widespread and remains largely confined to academic, tertiary, and high-volume laparoscopic or robotic centers where near-infrared imaging is available (13,29-31,33,34). Community and resource-limited hospitals often lack fluorescence-capable systems, limiting routine access (35). Current estimates suggest ICG is used in fewer than 15–25% of cholecystectomies nationwide, primarily in robotic cases or specialized programs (34).

There are several patient factors that can contribute to BDIs including male sex, age >60 years, obesity, cirrhosis, and adhesions from previous abdominal surgery (36,37). Factors such as acute cholecystitis, granulomatous cholecystitis, choledocholithiasis, and Mirizzi’s syndrome can impair achieving the CVS, increasing the risk of BDI (1,13). In the event of extreme difficulty in identification of anatomy, consensus guidelines recommend pausing intraoperatively to confirm CVS. If CVS cannot be safely obtained, bailout strategies endorsed in current safe cholecystectomy guidelines include a top down approach, subtotal cholecystectomy or conversion to open (15,16).

Percutaneous cholecystostomy (PC) is increasingly used as a temporizing measure for high-risk patients with acute cholecystitis. However, interval cholecystectomy following PC is associated with a higher rate of BDI (1.6–3.7%) compared to the general population (0.2–0.6%) (38,39). Optimal timing of interval cholecystectomy after PC remains debated; initial consensus recommended surgery at least 6 weeks from PC placement, with more recent reviews recommending surgery at 8 to 13 weeks after PC placement (40,41). Surgery within the first month after initial placement carries the highest risk of operative complications (42). PC tube removal can be considered prior to surgery following a successful clamping trial and may reduce operative complications but increases the risk of emergency cholecystectomy for recurrent cholecystitis (43).

The timing of cholecystectomy and surgeon experience both influence the risk of BDI. Early cholecystectomy during the index admission is associated with lower morbidity and fewer complications than delayed surgery, which is often technically more challenging due to inflammation and fibrosis (44-46). Data regarding after-hours operations are mixed. One single-center study found that 75% of BDIs occurred overnight or on weekends, though this is not consistently demonstrated in systematic reviews and population-based studies when controlling for patient factors and institutional resources (47-49). Surgeon factors further play a critical role: less experienced surgeons and lower institutional volume are associated with higher BDI rates, while specialized hepatopancreatobiliary expertise is protective (47,50). Collectively, these data support prioritizing early, daytime cholecystectomy when feasible and ensuring experienced surgical oversight—particularly for urgent or complex cases—to minimize the risk of BDI.

Classification of CBD injuries

Accurate classification of BDI is essential for guiding appropriate management and predicting outcomes (51,52). The Strasberg classification is the most commonly used system for categorizing injuries and is based on the anatomical location and the extent of damage. Injuries are classified from Type A to E as follows (14):

• Type A is the most common, consisting of a leak from the cystic duct or minor ducts in the gallbladder bed.
• Types B and C involve aberrant right-sectoral ducts with Type B representing occlusion and Type C representing transection with or without bile leak.
• Type D describes lateral injuries to major ducts without complete loss of continuity.
• Type E injuries involve the complete transections or strictures of the common hepatic duct, further subdivided by their distance from the hepatic confluence.
  • Type E1: transection/stricture >2 cm from the biliary confluence.
  • Type E2: transection/stricture <2 cm from the biliary confluence.
  • Type E3: transection/stricture at the hilum with an intact confluence.
  • Type E4: transection/stricture above the confluence with separation of the left and right ducts.
  • Type E5: injury to the aberrant right hepatic duct plus a concomitant injury to the common hepatic duct.

The proximity of the right hepatic artery (RHA) to the bile duct, often coursing posterior to the CBD, creates a risk of concomitant vascular injury when the CBD is mistakenly identified as the cystic duct. Concomitant vascular injury negatively impacts patient prognosis (53,54). Since the widely adopted Strasberg classification does not account for vascular injury, systems such as the Stewart-Way classification (55), the Hannover classification (56), and the ATOM (Anatomic, Time Of detection, Mechanism) (57) classification were developed to incorporate the presence of concurrent vascular injury.

Intraoperative detection

Early recognition of BDI is critical to achieving optimal patient outcomes (17,58,59). Approximately 25–40% of bile duct injuries are recognized intraoperatively (4,17). Bile staining in the operative field should invoke suspicions for BDI. Bile drainage from a location other than the gallbladder or bile draining from a tubular structure are concerning for BDI (1,17). BDI should be considered any time more than a single duct is ligated or divided (60-62). If there is suspicion of BDI intraoperatively, IOC and/or ICG should be used to assist in detection (1,17). Use of IOC has been associated with increased intraoperative detection of BDI and can be used to confirm ductal continuity or identify bile leaks (13,17). ICG fluorescence enables real-time assessment of the bile duct and detection of potential leakage, allowing surgeons to immediately verify ductal integrity (17).

Immediate intraoperative management

In cases where BDI is recognized intraoperatively, the primary goal is to control bile leakage and stabilize the patient. If hepatobiliary (HBP) expertise is not available for local repair, the best course of action is to do no further harm. Drains should be placed in the right upper quadrant and the patient should be transferred to a center with appropriate HPB expertise (13,17,63).

The method of repair will depend on the classification of the injury (Figure 1). For Strasberg C BDI, ligation of the accessory duct is appropriate provided it drains a small, non-essential segment. If the duct is ≥4 mm, Roux-en-Y Hepaticojejunostomy (RnY-HJ) may be required to drain that specific segment (17,63). For Strasberg D BDI, a direct repair with or without the placement of a T-tube is safe and effective (17,63). This is an appropriate approach for injuries that involve less than 50% of the wall of the duct (64). For Strasberg Type E BDI, the repair should be performed by an expert HPB surgeon as immediate repairs completed by a non-HPB surgeon are associated with worse patient outcomes (17,18,65,66). A tension free RnY-HJ is the gold standard for repair (17,67). Additional dissection in the hilum should be avoided as much as possible (17). Data demonstrates that RnY-HJ is safe and that, in the long-term, clinically relevant anastomotic strictures occur in ~13% of patients. The vast majority of these can be managed with percutaneous dilatation (68,69).

Figure 1 Algorithm for management of intraoperative bile duct injury. Management pathway for bile duct injury identified during cholecystectomy. Initial steps include recognition of abnormal biliary anatomy or bile leakage and stabilizing the patient. Minor injuries may be treated with primary repair or drainage, while major injuries typically require biliary reconstruction or referral to a specialized hepatopancreatobiliary center. BDI, bile duct injury; HPB, hepatopancreatobiliary.

Postoperative detection

The majority of BDI are detected in the post-operative period, accounting for 60–75% of all injuries (17,70). Figure 2 outlines a framework for approaching BDI recognized post-operatively. The two most common scenarios in unrecognized BDI are bile leak and bile duct stricture (64,71,72). When bile duct injuries are not recognized intraoperatively, they typically present within the first week post-operatively, though timing and nature of symptoms are linked to type and severity of the injury (5,73,74). Patient complaints may include abdominal pain, distention, nausea, emesis, fever and jaundice (75). If a surgical drain was placed and a bile leak develops, bilious drainage may be observed in the reservoir. Laboratory studies may demonstrate a leukocytosis and liver function tests may demonstrate elevated AST, ALT or bilirubin levels (63). Jaundice in the setting of an obstructive pattern on liver function tests is most frequent in the setting of obstruction or stricture. Patients may present with sepsis from biliary peritonitis and/or cholangitis, making source control the priority (64).

Figure 2 Algorithm for management of postoperative bile duct injury. Management pathway for bile duct injury recognized after cholecystectomy. Initial priorities include control of bile leak and sepsis with antibiotics, percutaneous drainage, and/or endoscopic or percutaneous biliary decompression. Subsequent evaluation with MRCP, ERCP, or PTC is used to define biliary anatomy and classify the injury. Minor injuries may be managed with endoscopic stenting, while more complex injuries are treated according to Strasberg classification, including ligation of small accessory ducts or Roux-en-Y hepaticojejunostomy for major ductal injuries. Delayed reconstruction is recommended when inflammation or sepsis is present. BDI, bile duct injury; ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging; PTC, percutaneous transhepatic cholangiography.

In addition to laboratory studies, imaging is key in the identification and classification of BDI (76,77). Ultrasound (US) in a non-invasive and easily accessible modality that can demonstrate the presence of large intraabdominal fluid collection and dilation of the bile ducts (71,77). Computed tomography (CT) may detect fluid collections with a higher sensitivity than US (71,76). If cross sectioning imaging is non-diagnostic, hepatobiliary scintigraphy (HIDA) can serve as an adjunct to confirm suspected leak, but provides limited ductal anatomic detail and may be less informative in the setting of high-grade obstruction or markedly impaired hepatocellular function (78). None of these imaging modalities are optimal for detecting the exact location of leak or stricture (79,80). MR cholangiopancreatography (MRCP) is considered the standard for detection of BDI. Non-invasive and with no radiation exposure for patients, MRCP provides an accurate anatomical picture of the biliary tree and can help delineate the injury, allowing for accurate classification of the injury (17,79,80). CT and MRCP with intravenous contrast will also assess for vascular injury (76,81-83).

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive form of imaging that can be used to delineate biliary anatomy and localize and classify BDIs. Diagnostic sensitivity of ERCP exceeds 98%. ERCP can be used to treat minor BDI through internal stenting for leakage, dilation of strictures, or sphincterotomy for decompression of the biliary tree (17,79,80,84). Ductal injuries that are extrahepatic, <5 mm in diameter, and not associated with abscess have an increased rate of successful intervention (85). Percutaneous transhepatic cholangiography (PTC) is an additional invasive method of evaluation of the biliary tree and can be used when endoscopic intervention fails or the injury requires access to the biliary tree more proximally. After mapping of the biliary tree, percutaneous transhepatic biliary drainage catheters may be placed for decompression and drainage, especially in the setting of cholangitis (86,87). ERCP and PTC can also be used in combination for a percutaneous-transhepatic-endoscopic rendezvous procedures to safely place a stent across the BDI (64,88).

Timing of BDI repair

The optimal timing of surgical repair in patients who present in a delayed manner after the index operation remains a topic of debate. Available recommendations are grounded primarily in meta-analyses and large observational cohorts, which are limited by variable timing definitions, referral patterns, and access to centers with HPB expertise (18,89-91). Generally, timing of repair falls into three categories in the literature: early (within 72 hours to 2 weeks post-operatively), intermediate (2–6 weeks post-operatively) and delayed (>6 weeks post-operatively). Delays in patient diagnosis or delay in patient referral to a tertiary center with HPB expertise may factor into where patients fall on this timeline (92). Repairs within the first 72 hours are performed before significant inflammation and tissue edema develop and may be ideal for the prompt resolution of bile leaks and peritonitis as well as reducing healthcare costs and readmissions (93,94). While patients with early BDI repair (<2 weeks) experience a benefit in morbidity, they have been shown to have a higher rate of post-operative stricture compared to late repair (89,90). Waiting until acute inflammation and ischemia have resolved (>6 weeks) has a more successful repair rate with lower risk of anastomotic stricture than patients with repairs completed in the intermediate period (18,52,89-91). Intermediate repair (between 2 and 6 weeks) has been demonstrated to have increased risk of morbidity and higher rate of stricture (89). A study of 614 patients from a prospectively collected dataset defined early repair as within a week of injury, intermediate repair as 8 days to 6 weeks and late repair as >6 weeks. Intermediate repair was associated with a higher risk of postoperative complications. The authors use a cutoff of within one week to ensure sepsis control, optimal nutritional status, and obtain essential imaging studies before proceeding to RnY-HJ. If the patient has not been optimized for repair within a week, delayed repair is performed. The authors delay repair for about 3–6 months to allow healing of the inflammatory changes to optimize the chance for a successful repair (95). Current SAGES-AHPBA guidelines make conditional recommendation in favor of delayed (>6 weeks) versus early (<6 weeks) definitive repair (96).

A multidisciplinary approach

Management of iatrogenic BDIs requires a multidisciplinary team integrating HPB surgeons, interventional radiologists, and endoscopists to optimize outcomes. Reconstruction demonstrates substantially better patency and lower stricture rates when performed at specialist HPB centers by experienced surgeons versus attempts at repair in non-specialist settings (65,97). Interventional radiology (IR) plays a critical role in diagnostic mapping via PTC and for percutaneous transhepatic biliary drainage to control leaks and sepsis as a bridge to delayed reconstruction (79,80,85,87). Endoscopists provide diagnostic and therapeutic intervention via ERCP such as stenting or sphincterotomy, particularly in cases recognized postoperatively (79,84,98). Early referral to specialized centers with a full multidisciplinary team is associated with improved repair rates and fewer failures compared to repairs in non-specialist settings (64,80,92).

Prognosis and outcomes

BDI carries substantial short- and long-term morbidity. The timing and severity of the injury, the length of time to recognition and repair, the surgeon’s experience and specialization, the presence of concomitant vascular injury and the degree of sepsis and inflammation at the time of repair all play a role in the prognosis of patients with BDI (17). Early referral to and repair by experienced hepatobiliary surgeons are the most important predictors of favorable outcomes (4,18,99).

In the early postoperative period, patients may face complications such as bile leak, abscesses, cholangitis, and sepsis requiring percutaneous or endoscopic drainage or reoperation. In the longer term, even after successful reconstruction, patients remain at risk for anastomotic stricture, recurrent cholangitis, secondary biliary cirrhosis, portal hypertension and liver failure (17). The reported stricture rate varies greatly in the literature, from 4 to 69%, though most studies report an incidence of around 10–20% (90,100,101). The median time to stricture formation varied between 11 and 30 months (4). The rate of secondary biliary stenosis is reported from 2.4% to 10.9%, and can be disastrous for patients, necessitating eventual liver transplant (4). The perioperative mortality rate ranges from 1.7–4.3%, dramatically higher than uncomplicated cholecystectomy (102,103). Additionally, BDI affects long-term survival with an increased 1-year (7.2% vs. 1.3%) and 5-year mortality rate (14.5% vs. 4.8%) compared to matched controls (104).

BDI may have a profound impact on patients’ quality of life (QoL). Studies using validated tools such as SF-36 show worse physical and mental component scores when compared with controls, particularly if the injury was not recognized intraoperatively or when patients required complex/delayed reconstructions (59,105,106). Patients with BDI may also experience loss of productivity in paid and unpaid work (100). Long-term follow-up and psychological support are essential in the care of these patients.

Limitations

Although multiple consensus guidelines exist regarding the prevention and management of BDI in laparoscopic cholecystectomy, high-quality randomized trials are limited, as BDI remains relatively rare and is challenging to study prospectively (13,17). Current recommendations are supported primarily by observational data and expert consensus rather than level I evidence, especially regarding timing of repair, the use of adjunct imaging, and choice of bailout strategy (13,17,18). In addition, multiple injury classification systems, definitions of repair timing, and outcome reporting limits study comparisons (4,17,18). Much of the available literature originates from high-volume tertiary referral centers, limiting generalizability to community settings where access to HPB expertise and advanced imaging platforms varies (17,65). Long-term outcomes such as QoL and functional recovery also remain inconsistently reported (4,105).

Further directions

Despite advances in prevention and reconstruction, several areas require further development. Ongoing debate remains regarding routine versus selective use of IOC and the broader adoption of ICG imaging, particularly in settings where resources and expertise vary (13,29-31). Similarly, while timing of repair has been extensively evaluated, inconsistent definitions and variable study designs continue to limit consensus (18,89-91,95). Future efforts should prioritize multicenter collaboration, standardized injury classification and reporting frameworks, and systematic evaluation of long-term outcomes. Emerging strategies including structured video review, simulation-based training, and image-guided technologies aimed at reducing cognitive error and anatomic misidentification also warrant further study (13,15).

Conclusions

BDI remains a serious complication of cholecystectomy, with significant short- and long-term consequences. Prevention through meticulous technique, obtaining a CVS and use of adjuncts such as IOC and ICG is paramount. When injuries occur, early recognition, accurate classification and appropriate management at a tertiary care center are essential to patient outcomes. A multidisciplinary team ensures comprehensive management from diagnosis through long term follow-up.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jeffrey M. Marks and Joshua L. Lyons) for the series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies” published in Annals of Laparoscopic and Endoscopic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-74/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-74/coif). The series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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