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Michel M. Murr, MD; Jean-François Gigot, MD; David M. Nagorney, MD; William S. Harmsen, MS; Duane M. Ilstrup, MS; Michael B. Farnell, MD

Arch Surg. 1999;134:604-610.

Hypothesis  The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients.

Design  Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997.

Setting  Academic tertiary referral center.

Main Outcome Measures  Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival.

Results  Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n=2 (3%), C: n=1 (1%), D: n=2 (3%), E₁: n=5 (8%), E₂: n=16 (27%), E₃: n=25 (42%), E₄: n=5 (8%), and E₅: n=3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean ± SEM, 3.7 ± 0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n=3), endoscopic dilation (n=1), and operative revision (n=1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively.

Conclusions  Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.

From the Departments of Surgery (Drs Murr, Gigot, Nagorney, and Farnell) and Health Sciences Research (Messrs Harmsen and Ilstrup), Mayo Clinic and Foundation, Rochester, Minn; Dr Murr is now with the Department of Surgery, University of South Florida, Tampa. Dr Gigot is now with the St Luc University Hospital, Louvain Medical School, Brussels, Belgium.

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