A 48-year-old woman undergoes laparoscopic cholecystectomy. Intraoperatively, the surgeon inadvertently transects the common hepatic duct. After recognizing the injury, what is the most appropriate management?

• A Primary end-to-end repair of the duct over a T-tube
• B Clip both ends and convert to open surgery for T-tube placement
• C Insert a biliary stent endoscopically as definitive treatment
• D Refer immediately to a hepatobiliary specialist center; Roux-en-Y hepaticojejunostomy is the definitive repair ✓

Explanation

Major bile duct injuries (Strasberg type E / Bismuth classification injuries involving the common hepatic duct) should be managed at a specialist hepatobiliary center. The gold-standard repair is Roux-en-Y hepaticojejunostomy performed by an experienced hepatobiliary surgeon, as primary end-to-end anastomosis over a T-tube has high stricture rates. Intraoperatively, the surgeon should recognize the injury, apply a clip to prevent biliary soiling, and convert if needed, then arrange urgent transfer. Outcomes are significantly better when repair is performed at a specialist center with expertise in biliary reconstruction.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.