Suspected bile duct injury after or during cholecystectomy
Adults. Bile in the field or drain, bile leak, jaundice, pain or sepsis after cholecystectomy.
All Pathways
Hepatobiliary SurgeryEmergency
Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025)
Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025): Suspected bile duct injury after or during cholecystectomy → Injury found after su...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Decision Injury found after surgery (not in theatre)?
Yes: found after the operation. No: recognised in theatre.
- If Yes
03Action Found after surgery: investigate early
Any patient who does not recover quickly after cholecystectomy. Pregnant: ultrasound and MRCP without gadolinium first; involve obstetrics.
- Alarm signs: pain, distension, fever, jaundice, nausea or vomiting, bile in drain or wound
- Bloods: bilirubin, ALP, GGT, AST, ALT, albumin, FBC; if unwell add CRP, lactate, blood cultures
- Contrast CT abdomen (triphasic) first: collection, biloma, duct dilatation, arterial injury
- MRCP (with hepatobiliary contrast if available) to define the level of injury
- HIDA scan if a leak is suspected but not shown
- Discuss with the HPB centre early
04Decision Sepsis, bile peritonitis or cholangitis?
Control sepsis before any definitive repair.
- If Yes
05Warning Sepsis or peritonitis: control the source first
No definitive bile duct repair while septic or inflamed. Refer to an HPB centre. Penicillin allergy: local (eTG) regimen. On anticoagulant or antiplatelet: plan with the proceduralist; do not delay drainage.
- IV broad-spectrum antibiotics within 1 h (e.g. piperacillin-tazobactam or meropenem); resuscitate
- Diffuse bile peritonitis: urgent lavage and drainage (laparoscopic if possible)
- Biloma: percutaneous drainage. Septic with blocked ducts: PTBD or ERCP drainage
06Action Classify the injury (Strasberg)
Use CT, MRCP and cholangiography. Also record any arterial or portal vein injury.
- A: leak from cystic duct or small ducts in the liver bed
- B: occlusion of an aberrant right hepatic duct
- C: leak from a cut aberrant right hepatic duct (not joined to the CBD)
- D: lateral injury to the CHD or CBD (duct still in continuity)
- E: CHD or CBD cut or occluded. E1 stump over 2 cm; E2 stump under 2 cm; E3 hilar, confluence intact; E4 confluence destroyed; E5 with aberrant right duct injury
07Decision Which injury type?
Type E, D, B or C, or A. Each next step names its type.
- E
08Action Type E (CHD or CBD cut or occluded): transfer to HPB centre
Needs surgical reconstruction by an HPB surgeon. Repair by a non-HPB surgeon worsens outcome.
- Drain collections; PTBD if septic with a blocked duct; targeted antibiotics; nutrition
- Repair within 72 h only at an HPB centre, with no sepsis and no vascular injury
- Otherwise delay repair until sepsis and inflammation settle: at least 3 weeks (WSES); SAGES-AHPBA 2025 favours after 6 weeks
- Late stricture: Roux-en-Y hepaticojejunostomy
09Decision Arterial or portal vein injury on CT angiography?
Right hepatic artery injury occurs in about 1 in 4 BDIs.
- If Yes
10Warning Vasculobiliary injury: delay repair, HPB or transplant centre
Assess liver ischaemia before any repair.
- Delay biliary repair for weeks to assess ischaemia; do not repair at the index operation
- Isolated right hepatic artery injury: often tolerated; no routine immediate repair
- Portal vein injury, combined injury or liver necrosis: emergency HPB or transplant centre review
11Action Type E or large type D: definitive surgical repair
HPB centre, once sepsis and inflammation have settled.
- Roux-en-Y hepaticojejunostomy; hepaticoduodenostomy is an acceptable option
- Tension-free mucosa-to-mucosa anastomosis to healthy, well-perfused duct
- Open or minimally invasive: either, by surgeon expertise
- Selected patients: nonoperative definitive repair (endoscopic or percutaneous) is an option; the HPB team decides
12Action Follow-up after repair or stenting
Long term, led by the HPB team.
- Anastomotic stricture after hepaticojejunostomy: 10 to 20%, median onset 11 to 30 months
- Regular review with LFTs for years, not months
- Fever, rigors, jaundice or rising ALP: urgent review for cholangitis or stricture (MRCP)
- Stent in place: record and keep the removal or exchange date
13End Long-term surveillance
LFTs and imaging for late stricture, cholangitis or secondary biliary cirrhosis; quality of life.
If No- Path rejoins step 11Shared downstream outcome
- D
14Action Type D (lateral tear of CHD or CBD): HPB advice
Duct still in continuity. Refer to or discuss with an HPB centre.
- Small tear, continuity on MRCP: ERCP with stent
- At surgery, small clean tear: direct repair with fine absorbable suture, with or without T-tube
- Tear of half the circumference or more, tissue loss, or thermal or ischaemic injury: treat as type E (Roux-en-Y hepaticojejunostomy)
- Path rejoins step 12Shared downstream outcome
- Large tear
- Path rejoins step 09Shared downstream outcome
- B or C
15Action Type B or C (aberrant right hepatic duct): HPB referral
ERCP does not show or seal an aberrant right duct that is not joined to the CBD.
- Type B, no symptoms: observe; the drained liver sector may atrophy
- Type B with pain or cholangitis: HPB centre
- Type C (leaking): percutaneous drainage of the collection and HPB centre for definitive care
- Path rejoins step 12Shared downstream outcome
- A
16Action Type A (cystic duct or liver-bed leak): drain, then ERCP
On anticoagulant or antiplatelet, or coagulopathy: tell the endoscopist; a stent without sphincterotomy lowers bleeding risk.
- Drain in place, patient well: observe for the first hours
- Collection and no drain: percutaneous drainage
- Not improving or getting worse: ERCP with sphincterotomy and plastic stent
- Remove the stent after about 4 to 8 weeks if cholangiogram shows the leak has healed
- ERCP fails or not possible: PTBD and HPB referral
- Path rejoins step 12Shared downstream outcome
If No- Path rejoins step 06Shared downstream outcome
If No17Warning In theatre: stop and call an HPB surgeon
Do not attempt repair unless an HPB surgeon is present; repair by a non-HPB surgeon worsens outcome. Only exception: a cystic duct stump or liver-bed duct leak (type A): close it (clip, ligature or suture) and drain.
- Stop dissection. Do not dissect the hilum further.
- Call an HPB surgeon now; get a second surgeon's opinion.
- Define the injury: cholangiogram (IOC) or ICG if available.
18Decision HPB surgeon present and no vascular injury?
Vasculobiliary injury: do not repair in theatre, even by an HPB surgeon.
- If Yes
19Action HPB surgeon present, no vascular injury: repair in theatre
Repair on table or within 72 h, only with HPB expertise.
- Minor injury: type A clip or suture the leak; type D small clean tear direct repair with or without T-tube; subhepatic drains
- Type C (cut aberrant right duct): under 3 mm ligate; 3 mm or more hepaticojejunostomy
- Major injury (type E), tissue loss or ischaemia: Roux-en-Y hepaticojejunostomy, or drain and delay (SAGES-AHPBA 2025 favours repair after 6 weeks)
- Isolated right hepatic artery injury: no routine immediate arterial repair
- Record the injury: drawing, anatomy, cholangiogram, energy device, video
- Path rejoins step 12Shared downstream outcome
If No20Action No HPB surgeon, or vascular injury: drain now, repair later
Control bleeding first with pressure or packing; no blind clips or diathermy near the hilum. Then place drains, close and transfer to an HPB centre. Do not attempt repair.
- Subhepatic drain(s) near the injury; do not dissect further
- Do not convert to open only to stage the injury
- Consider IV broad-spectrum antibiotics; give them if prior cholecystitis, cholangitis or biliary stent. Send bile culture
- Remote site or long transfer: optimise local care (drainage, antibiotics, fluids) before transfer
- Record the injury: drawing, anatomy, cholangiogram, energy device, video
- Path rejoins step 04Shared downstream outcome
Guideline Source
2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy (World J Emerg Surg 2021;16:30); repair timing and type updated to SAGES-AHPBA 2025 guideline (Surg Endosc 2026;40:1-17, doi 10.1007/s00464-025-12352-6)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Repair timing for major injury is debated: WSES allows early repair at an HPB centre; SAGES-AHPBA 2025 conditionally favours repair after 6 weeks (low certainty).
- Adults only. Every major injury (type E, vasculobiliary) needs an HPB centre; this pathway does not replace HPB advice.
- Evidence is mostly retrospective and low certainty.
- Injuries found years after surgery (late strictures) are only briefly covered.
Contraindicated Populations
Children (seek paediatric surgical advice)Bile duct injury from trauma or liver transplant (different pathways)
Applicable Regions
USEUUKAU
AU: Refer to a tertiary HPB unit; use the state retrieval service for transfer. Antibiotics: follow Therapeutic Guidelines (eTG) for intra-abdominal sepsis.
EU: WSES 2020 BDI guideline; EAES ATOM classification.
US: SAGES-AHPBA 2025 guideline for surgical repair of bile duct injury.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025)?
The Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy (World J Emerg Surg 2021;16:30); repair timing and type updated to SAGES-AHPBA 2025 guideline (Surg Endosc 2026;40:1-17, doi 10.1007/s00464-025-12352-6).
What guideline is the Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025) based on?
This algorithm is based on 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy (World J Emerg Surg 2021;16:30); repair timing and type updated to SAGES-AHPBA 2025 guideline (Surg Endosc 2026;40:1-17, doi 10.1007/s00464-025-12352-6) (DOI: 10.1186/s13017-021-00369-w).
What are the limitations of the Bile Duct Injury after Cholecystectomy (WSES 2020, SAGES-AHPBA 2025)?
Known limitations include: Repair timing for major injury is debated: WSES allows early repair at an HPB centre; SAGES-AHPBA 2025 conditionally favours repair after 6 weeks (low certainty).; Adults only. Every major injury (type E, vasculobiliary) needs an HPB centre; this pathway does not replace HPB advice.; Evidence is mostly retrospective and low certainty.; Injuries found years after surgery (late strictures) are only briefly covered.. Individual patient factors may require deviation from these recommendations.
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