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Abstract Summary Over the last two decades, laparoscopic cholecystectomy (LC) has gained worldwide acceptance and considered to be as ”gold standard” in the surgical management of symptomatic calcular cholecystitis. Most major bile duct injuries are as a result of misidentification of ductal structures. Technical complications, such as thermal injury, tenting of the ducts, and dissecting too deeply, are less frequent causes of bile duct injuries. Surgeons’ inexperience, acute inflammation, cystic duct impaction, excessive bleeding, and aberrant anatomy are all risk factors for bile duct injuries Approximately 75% of patients with bile duct injuries will have a delayed presentation ranging from days to months, the variety of imaging options for the postcholecystectomy patient who presents with pain, fever, or jaundice; ultrasound and computed tomography (CT) are both good modalities for assessing fluid collections and bile duct dilatation, and can provide guidance for percutaneous drainage. A hepatobiliary iminodiacetic acid (HIDA) scan can compliment the evaluation by determining whether there is complete ductal obstruction, leakage of bile, or both. Summary 159 Understanding the anatomy of the gallbladder and the extra hepatic biliary system is essential to all clinicians caring for patients with hepatobiliary disorders. Biliary anomalies are not uncommon and over 50% of all patients undergoing a biliary tract procedure will have either a ductal or an arterial anomaly. The failure to recognize such a congenital problem can result in significant per operative morbidity. The liver, gallbladder and small intestine are connected by a series of thin tubes called bile ducts. The bile ducts are part of the digestive system. The bile ducts and gallbladder are also part of the biliary system, or biliary tract. The extrahepatic biliary tract is a closed system designed to collect, store, and concentrate bile secreted by the liver and that is intermittently delivered to the duodenum through the bile ducts. Bile contains bile salts, a key component involved in the digestion and absorption of fats and liposolubles vitamins. The motor functions of the biliary tract are integrated with the rest of the gastrointestinal tract in the fasting and digestive periods through complex neurohormonal mechanisms that include the vagus and splanchnic nerves and the hormone CCK as the major actors. Summary 160 Laparoscopic surgery is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm) elsewhere in the body. Also called minimally invasive surgery (MIS) bandaid surgery or keyhole surgery. Bile duct injury (BDI) has long been recognized as serious complication of cholecystectomy and its occurrence has been highlighted with introduction of laparoscopic surgery. Injury to the biliary tree is reported in approximately 0.2% of patients undergoing open cholecystectomy The precise rate of BDI in laparoscopic era is however, difficult to determine. A recent study from the west of Scotland does suggest that the bile duct injury rate had fallen from 0.8% to 0.4% in recent years It was found that the fibrosis in the triangle of Calot, acute cholecystitis, obesity, local hemorrhage, variant anatomy and fat in the portahepatis were identified as risk factors Undoubtedly, surgical experience is a significant risk factor in the occurrence of bile duct injuries with the incidence appearing to fall as lap. expertise increases In Bithmus classification scheme, five strictures type are recognized, reflecting the location with respect to the hepatic Summary 161 duct confluence (Types 1-2-3-4) or involvement of an aberrant right sectoral hepatic duct with or without a concomitant hepatic duct stricture type Prevention of the injury through education and attention to anatomy is the most effective form of prevention. Prevention of biliary injury by continuing to emphasize safe technical aspects of the procedure during residency training, by continuing to evaluate our results in practice, and by promoting ongoing education programs such as this forum to help surgeons achieve this goal. Complications that we see currently are no longer a result of a learning curve experience Epidemiologists classify prevention of health problems into primary and secondary. Primary prevention involves steps aimed at limiting the incidence of disease/complication by controlling causes and risk factors. Secondary prevention aims at early detection of the problem and its prompt and effective management. The technical considerations for safely performing laparoscopic cholecystectomy include proper anatomic dissection and the risks of instrument malfunction. Some risk factors include operation on the acutely inflamed gallbladder, thermal injury to the bile duct, and tenting injuries The management of bile duct injuries generally is best performed in major medical centers by experienced Summary 162 multidisciplinary teams. This multidisciplinary approach and improved surgical experience have led to a significant improvement in the short-term results from the treatment of these patients. Most patients with a bile duct injury after laparoscopic cholecystectomy present during the very early postoperative period in one of two ways. Some patients present with biliary obstruction, manifested as progressive elevation of liver function test levels, particularly total bilirubin and alkaline phosphatase levels. These changes often can be seen as early as postoperative day 2 or 3 Not all late biliary injuries require intervention. Some patients may remain entirely asymptomatic, the injury being diagnosed by a coincidental abdominal ultrasound or blood test showing elevated liver function. Unneeded intervention in such asymptomatic patients may not be necessary or desirabl |