الفهرس 
Anatomy of the liver and the biliary tractOnly 14 pages are availabe for public view
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Abstract
Surgical procedures performed within the biliary tract are very
common. The incidence of IBDI has increased recently, and has been
associated with increased use of laparoscopic cholecystectomy
worldwide. It is essential to be careful in the proper visualization of the
surgical area and the identification of structures before ligation or
transsection in order to decrease the risk of bile duct injuries during
surgery.Anatomical anomalies of the bile ducts and hepatic arteries
significantly increase the risk of IBDI. The most frequent cause of IBDI
is misidentification of the bile duct. About 70%-80% of all IBDI are a
consequence of misidentification of biliary anatomy .
When biliary injury develops, early recognition and appropriate
treatment are most important. Early and correct treatment allows
avoidance of serious complications in patients with IBDI.
The best treatment for an iatrogenic wound of the biliary tract is
prevention by adequate education of surgeons in the performance of a
safe technique of cholecystectomy. Great care must be exercised during
other biliary tract operations, difficult gastrectomies, pancreatic
operations, endoscopic biliary tract investigations and operations in order
to preserve the bile ducts. It is very important for every surgeon to be
aware of the variants of biliary duct anatomy. It is recommended that, the
routine use of intra-operative cholangiography in association with carefuldissection of the blood supply to avoid any unexpected bleeding is
essential.
During cholecystectomy cystic structures can be identified by
critical view of safety technique, by cholangiography, by infundibular technique, or by dissection of the main bile duct with visualization of the
cystic duct or common duct insertion .
When a laparoscopic procedure is performed by two surgeons the
incidence of BDI significantly decreases, and thus a second opinion from
a colleague before cutting any suspicious vital structure may be
recommended .The negative effects of conversion or even aborting the procedure
are minor compared with the negative effect of BDI. Failure of
progression of the dissection, inability to grasp and retract the
gallbladder, anatomic ambiguity, and poor visualization of the field due
to bleeding should trigger the surgeon not to go on and consider
alternative methods. Conversion to open procedure, proceeding with
partial cholecystectomy, or even aborting the operation and placing
cystostomy tube are all viable and acceptable options to decrease the risk
of BDI. After partial resection the remnants of the gallbladder may be
removed later on.Injuries recognized during the operation must be repaired
immediately by a specific technique suited to the specific injury. The
injury should be repaired by an experienced hepatobiliary surgeon. If it is
impossible, a patient should be transferred to a referral hepatobiliary
surgery center, after adequate drainage of a subhepatic region.
A delayed elective reconstruction is associated with fewer
complications compared to acute repair under suboptimal circumstances
and has a success rate of 90% in experienced centers. Diagnostic work up
and treatment of bile duct injuries needs a multidisciplinary approach
(gastroenterologists, radiologists, surgeons). Surgical reconstruction for
delayed detected bile duct injuries in the early postoperative phase isassociated with a higher risk for complication compared with elective
repair after 6-8 weeks.