Is there a place for endoscopic management in postcholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery.Previously,surgery was the primary treatment for bile duct injuries(BDI).The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures.Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years.Patient management,including the specific technique,is typically impacted by local knowledge and the kind and severity of the injury.Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction.Based on the damage features of BDI,therapeutic options include endoscopic duodenal papillary sphincterotomy,endoscopic nasobiliary drainage,and endoscopic biliary stent implantation.

Mechanism of Dynamic Near-infrared Fluorescence Cholangiography of Extrahepatic Bile Ducts and Applications in Detecting Bile Duct Injuries Using Indocyanine Green in Animal Models

Fluorescence intraoperative cholangiography（IOC） is a potential alternative for identifying anatomical variation and preventing iatrogenic bile duct injuries by using the near-infrared probe indocyanine green（ICG）. However, the dynamic process and mechanism of fluorescence IOC have not been elucidated in previous publications. Herein, the optical properties of the complex of ICG and bile, dynamic fluorescence cholangiography and iatrogenic bile duct injuries were investigated. The emission spectrum of ICG in bile peaked at 844 nm and ICG had higher tissue penetration. Extrahepatic bile ducts could fluoresce 2 min after intravenous injection, and the fluorescence intensity reached a peak at 8 min. In addition, biliary dynamics were observed owing to ICG excretion from the bile ducts into the duodenum. Quantitative analysis indicated that ICG-guided fluorescence IOC possessed a high signal to noise ratio compared to the surrounding peripheral tissue and the portal vein. Fluorescence IOC was based on rapid uptake of circulating ICG in plasma by hepatic cells, excretion of ICG into the bile and then its interaction with protein molecules in the bile. Moreover, fluorescence IOC was sensitive to detect bile duct ligation and acute bile duct perforation using ICG in rat models. All of the results indicated that fluorescence IOC using ICG is a valid alternative for the cholangiography of extrahepatic bile ducts and has potential for measurement of biliary dynamics.

Percutaneous transhepatic cholangioscopy-assisted biliary polypectomy for local palliative treatment of intraductal papillary neoplasm of the bile duct

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)is a premalignant biliarytype epithelial neoplasm with intraductal papillary or villous growth.Currently reported local palliative therapeutic modalities,including endoscopic nasobiliary drainage,stenting and biliary curettage,endoscopic biliary polypectomy,percutaneous biliary drainage,laser ablation,argon plasma coagulation,photodynamic therapy,and radiofrequency ablation to relieve mechanical obstruction are limited with weaknesses and disadvantages.We have applied percutaneous transhepatic cholangioscopy(PTCS)-assisted biliary polypectomy(PTCS-BP)technique for the management of IPNB including mucin-hypersecreting cast-like and polypoid type tumors since 2010.AIM To assess the technical feasibility,efficacy,and safety of PTCS-BP for local palliative treatment of IPNB.METHODS Patients with mucin-hypersecreting cast-like or polypoid type IPNB and receiving PTCS-BP between September 2010 and December 2019 were included.PTCS-BP was performed by using a half-moon type snare with a soft stainless-steel wire,and the tumor was snared and resected with electrocautery.The primary outcome was its feasibility,indicated by technical success.The secondary outcomes were efficacy,including therapeutic success,curative resection,and clinical success,and safety.RESULTS Five patients(four with mucin-hypersecreting cast-like type and one with polypoid type IPNB)were included.Low-and high-grade intraepithelial neoplasia(HGIN)and recurrent IPNB with invasive carcinoma were observed in one,two,and two patients,respectively.Repeated cholangitis and/or obstructive jaundice were presented in all four patients with mucin-hypersecreting cast-like type IPNB.All five patients achieved technical success of PTCS-BP.Four patients(three with mucin-hypersecreting cast-like type and one with polypoid type IPNB)obtained therapeutic success;one with mucin-hypersecreting cast-like type tumors in the intrahepatic small bile duct and HGIN had residual tumors.All four patients with mucin-hypersecreting IPNB achieved clinical success.The patient with polypoid type IPNB achieved curative resection.There were no PTCS-BP-related serious adverse events.CONCLUSION PTCS-BP appears to be feasible,efficacious,and safe for local palliative treatment of both mucin-hypersecreting cast-like and polypoid type IPNB.

Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma: A single-center retrospective study in South Korea

BACKGROUND Intrahepatic duct(IHD)stones are among the most important risk factors for cholangiocarcinoma(CCC).Approximately 10%of patients with IHD stones develop CCC;however,there are limited studies regarding the effect of IHD stone removal on CCC development.AIM To investigate the association between IHD stone removal and CCC development.METHODS We retrospectively analyzed 397 patients with IHD stones at a tertiary referral center between January 2011 and December 2020.RESULTS CCC occurred in 36 of the 397 enrolled patients.In univariate analysis,chronic hepatitis B infection(11.1%vs 3.0%,P=0.03),carbohydrate antigen 19-9(CA19-9,176.00 vs 11.96 II/mL,P=0.010),stone located in left or both lobes(86.1%vs 70.1%,P=0.042),focal atrophy(52.8%vs 26.9%,P=0.001),duct stricture(47.2%vs 24.9%,P=0.004),and removal status of IHD stone(33.3%vs 63.2%,P<0.001)were significantly different between IHD stone patients with and without CCC.In the multivariate analysis,CA19-9>upper normal limit,carcinoembryonic antigen>upper normal limit,stones located in the left or both lobes,focal atrophy,and complete removal of IHD stones without recurrence were independent factors influencing CCC development.However,the type of removal method was not associated with CCC risk.CONCLUSION Complete removal of IHD stones without recurrence could reduce CCC risk.

Classification and management of bile duct injuries

To review the classification and general guidelines for treatment of bile duct injury patients and their long term results. In a 20-year period, 510 complex circumferential injuries have been referred to our team for repair at the Instituto Nacional de Ciencias Médicasy Nutrición "Salvador Zubirán" hospital in Mexico City and 198 elsewhere (private practice). The records at the third level Academic University Hospital were analyzed and divided into three periods of time: GⅠ-1990-99 (33 cases), G Ⅱ2000-2004 (139 cases) and GⅢ2004-2008 (140 cases). All patients were treated with a Roux en Y hepatojejunostomy. A decrease in using transanastomotic stents was observed (78% vs 2%, P = 0.0001). Partial segment Ⅳ and Ⅴ resection was more frequently carried out (45% vs 75%, P = 0.2) (to obtain a high bilioenteric anastomosis). Operative mortality (3% vs 0.7%, P = 0.09), postoperative cholangitis (54% vs 13%, P = 0.0001), anastomosis strictures (30% vs 5%, P = 0.0001), short and long term complications and need for reoperation (surgical or radiological) (45% vs 11%, P = 0.0001) were significantly less in the last period. The authors concluded that transition to a high volume center has improved long term results for bile duct injury repair. Even interested and tertiary care centers have a learning curve.

Isolated right posterior bile duct injury following cholecystectomy:Report of two cases

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury(BDI)during cholecystectomy.Isolated right posterior BDI may in particular be a challenge for both diagnosis and management.Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy.Despite effective external biliary drainage from the liver hilum in both cases,there was a persistent biliary leak observed which was not visible on endoscopic retrogradecholangiogram.Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI.These were treated with a delayed bisegmental(segments 6 and 7)liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up.This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Classification of iatrogenic bile duct injury

BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords 'bile duct injury', 'cholecystectomy', and 'classification'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi’an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.

Robotic assisted Roux-en-Y hepaticojejunostomy in a post-cholecystectomy type E2 bile duct injury

Roux-en-Y hepaticojejunostomy anastomosis is the treatment of choice for common hepatic duct injury type E2.It has been performed laparoscopically with the advancement of laparoscopic skill.Recently,a telemanipulative robotic surgical system was introduced,providing laparoscopic instruments with wrist-arm technology and 3-dimensional visualization of theoperative field.We present a case of 36-year-old female patient who had undergone elective cholecystectomy2 mo ago for gall stones and had a common bile duct injury during surgery.As the stricture was old and complete it could not be tackled endoscopically.We did a laparoscopic assisted adhesiolysis followed by robotic Roux-en-Y hepaticojejunostomy.No intraoperative complications or technical problems were encountered.Postoperative period was uneventful and she was discharged on the 4th postoperative day.At followup,she is doing well without evidence of jaundice or cholangitis.This is the first reported case of robotic hepaticojejunostomy following common bile duct injury.The hybrid technique gives the patient benefit of laparoscopic adhesiolysis and robotic suturing.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries(IBDI)are still a challenge for surgeons.The most frequently,they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world.Endoscopic techniques are recommended as initial treatment of IBDI.When endoscopic treatment is not effective,surgery is considered.Different surgical biliary reconstructions are performed in most patients in IBDI.Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI.In some patients with complex IBDI,hepatectomy is required.Recently,Liet al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy(LC).Authors concluded that hepatectomy might be necessary to manage early or late complications after LC.The study showed that proximal IBDI(involving hepatic confluence)and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series.Authors distinguished two main groups of patients that require liver resection in IBDI:those with an injury-induced liver necrosis necessitating early intervention,and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis.In this commentary,indications for hepatectomy in patients with IBDI are discussed.Complex biliovascular injuries as indications for hepatectomy are presented.Short-and long-term results in patients following liver resection for IBDI are also discussed.Hepatectomy is not a standard procedure in surgical treatment of IBDI,but in some complex injuries it should be considered.

Non-image diagnosis of bile duct injury during laparoscopic cholecystectomy

Objective: To evaluate the role of simple non-imagetechnique in intraoperative diagnosis of bile duct in-jury (BDI).Methods: BDI was highly suspected at the original la-paroscopic cholecystectomy (LC) when the following 3abnormal findings were noted: the 'cystic duct' stump(the common bile duct stump actually) markedly re-tracted down to the duodenum; bile leakage from theporta hepatis; abnormal mucosal patch attached to the'cystic duct' stump of the removed gallbladder. Allcases of suspected BDI were converted to have laparo-tomy. Image techniques such as intraoperative cholan-giography or ultrasonography were not utilized forrecognition of BDI in all 9 patients.Results: BDI in 4 of the 9 patients was suspected ac-cording to 1-3 abnormal intraoperative findings de-scribed above. The four patients were subjected imme-diately to converted laparotomy. Abnormal findingswere not observed or misinterpreted in the other 5misdiagnosed patients.Conclusions: Timely recognizing whether BDI occursshould be considered as a routine procedure ofLC. Negligence of operators to the abnormalities of theoriginal LC, is the main cause of misdiagnosis forBDL. Simple non-image approaches such as close ob-servation of these abnormalities can make timely diag-nosis for most BDIs during the original LC.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries(BDIs)are difficult to avoid absolutely when the biliary tract has a malformation,such as accessory hepatic duct.Here,we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

Isolated segmental,sectoral and right hepatic bile duct injuries

The treatment of isolated segmental, sectoral and right hepatic bile duct injuries is controversial. Nineteen patients were treated over a 26-year period. Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery; 3 over a T-tube, 1 with a Roux-en-Y. These patients had an uneventful recovery. The second group consisted of 5 patients in whom the duct was ligated; 4 developed infection, 3 of which required drainage and biliary repair. Two patients had good long-term outcomes; the third developed a late anastomotic stricture requiring further surgery. The fourth patient developed a small bile leak and pain which resolved spontaneously. The fifth patient developed complications from which he died. The third group was comprised of 4 patients referred with biliary peritonitis; all underwent drainage and lavage, and developed biliary fistulae, 3 of which resolved spontaneously, 1 required Roux-en-γ repair, with favorable outcomes. The fourth group consisted of 6 patients with biliary fistulae. Two patients, both with an 8-wk history of a fistula, underwent Roux-en-γ repair. Two others also underwent a Roux-en-γ repair, as their fistulae showed no signs of closure. The remaining 2 patients had spontaneous closure of their biliary fistulae. A primary repair is a reasonable alternative to ligature of injured duct. Patients with ligated ducts may develop complications. Infected ducts require further surgery. Patients with biliary peritonitis must be treated with drainage and lavage. There is a 50% chance that a biliary fistula will close spontaneously. In cases where the biliary fistula does not close within 6 to 8 wk, a Roux-en-γ anastomosis should be considered.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury:A multicenter study

Background:Bile duct injury(BDI)after cholecystectomy remains a significant surgical challenge.No guideline exists to guide the timing of repair,while few studies compare early versus late repair BDI.This study aimed to analyze the outcomes in patients undergoing immediate,intermediate,and delayed repair of BDI.Methods:We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020.The patients were divided into three groups based on the time of BDI reconstruction.Group 1 underwent an immediate reconstruction(within the first 72 hours post-cholecystectomy,n=156);group 2 underwent an intermediate reconstruction(from 4 days to 6 weeks post-cholecystectomy,n=75),and group 3 underwent delayed reconstruction(after 6 weeks post-cholecystectomy,n=181).Results:Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3.Favorable outcome was observed in 111(71.2%)patients in group 1,31(41.3%)patients in group 2,and 157(86.7%)patients in group 3(P=0.0001).Multivariate analysis identified that complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1,the use of external stent was an independent factor of favorable outcome in group 2,and level E4 BDI was an independent factor of unfavorable outcome in group 3.Transected BDI and level E4 BDI were independent factors of unfavorable outcome.Conclusions:Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI.Complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Prevention of common bile duct injury during laparoscopic cholecystectomy

BACKGROUND: Since the widespread adoption of laparoscopic cholecystectomy (LC) in the late 1980s, a rise in common bile duct (CBD) injury has been reported. We analyzed the factors contributing to a record of zero CBD injuries in 10 000 consecutive LCs. METHODS: The retrospective investigation included 10 000 patients who underwent LC from July 1992 to June 2007. LC was performed by 4 teams of surgeons. The chief main surgeon of each team has had over 10 years of experience in hepatobiliary surgery. Calot's triangle was carefully dissected, and the relationship of the cystic duct to the CBD and common hepatic duct was clearly identified. A clip was applied to the cystic duct at the neck of the gallbladder and the duct was incised with scissors proximal to the clip. The cystic artery was dissected by the same method. Then, the gallbladder was dissected from its liver bed. A drain was routinely left at the gallbladder bed for 1-2 days postoperatively. RESULTS: No CBD injuries occurred in 10 000 consecutive LCs, and there were 16 duct leaks (0.16%). Among these there were 10 Luschka duct leaks (0.1%) and 6 cystic duct leaks (0.06%). Four hundred thirty cases were converted to open cholecystectomy (OC), giving a conversion rate of 4.3%. After a mean follow-up of 17.5 months (range 6-24 months), no postoperative death due to LC occurred, and good results were observed in 95% of the patients. CONCLUSIONS: In our 10 000 LCs with zero CBD injuries, the techniques used and practices at our department have been successful. Surgeon's expertise in biliary surgery, preoperative imaging, precise operative procedures, and conversion from LC to OC when needed are important measures to prevent CBD injuries.

Iatrogenic bile duct injury with loss of confluence

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4(Bismuth Ⅳ) bile duct injuries. METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo(median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.RESULTS: Patients were divided in three groups: G1(n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2(n = 26): Roux-en-Y portoenterostomy. G3(n = 6): Double(right and left) Rouxen-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.CONCLUSION: Loss of confluence represents a surgicalchallenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis(neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.

Pedicled omental patch as a bridging procedure for iatrogenic bile duct injury

Iatrogenic bile duct injuries during cholecystectomy can present as fulminant intra-abdominal sepsis which precludes immediate repair or biliary reconstruction.We report the case of a 29-year-old female patient who sustained a bile duct injury after an open cholecystectomy in a neighboring country.She presented to our institution 22 d after initial surgery with septic shock and multiple intra-abdominal collections.Endoscopic retrograde cholangiography revealed a large common hepatic duct defect corresponding to a Strasberg type D bile duct injury.Definitive reconstruction such as a hepaticojejunostomy cannot be performed due to the presence of dense adhesions with infected and friable tissues.She underwent a combination of endoscopic biliary stenting and pedicled omental patch repair of the bile duct to control bile leak and sepsis as a bridging procedure to definite hepaticojejunostomy three months later.

Factors influencing the results of treatment of bile duct injuries during laparoscopic cholecystectomy

BACKGROUND: The short-term results of repair of lapa- roscopic bile duct injuries have been well discussed, but the long-term results have been rarely reported. This study was undertaken to evaluate the factors influencing the outcome of repair of bile duct injuries caused by laparoscopic chole- cystectomy. METHODS: The outcomes of repair of bile duct injuries caused by laparoscopic cholecystectomy in 31 patients were reviewed retrospectively, and the effects of injury recogni- tion, cholangiography, repair modality and techniques on the long-term results were analyzed. RESULTS: Bile duct injuries were repaired successfully in 19 (95%) of 20 patients with injuries who had been recog- nized intraoperatively, and in 10 (90%) of 11 patients with injuries who had been recognized postoperatively. Repair was successful in 29 (93% ) of the 31 patients after complete cholangiography. Closure of partial division, laceration, or small perforation of the bile duct with or without T tube drainage was satisfactory in the 23 patients. End to end re- pair over T tube was successful in 2 transection patients, who were detected intraoperatively. Roux-en-Y hepatico- jejunostomy was used successfully to repair transection, ex- cision or stricture of the bile duct in 4 of 5 patients (80% ). CONCLUSION: Early detection of bile duct injuries caused by laparoscopy, complete evaluation of the biliary duct, and appropriate surgical modality and techniques are help- ful to improve the results of repair for laparoscopic bile duct injuries.