LC is the most common cause of iatrogenic bile duct injury [10]. Some patients are identified and repaired intraoperatively, but most cases are discovered postoperatively when the damage is more severe [11–12]. The timing of postoperative repair surgery for LC-related bile duct injury is a subject of ongoing debate [13]. Many experts consider 4–6 weeks post-LC as a critical cut-off point, dividing it into early and late (or deferred) repair [14]. By this time, infection-induced edema typically subsides, reducing the risk of infection and improving the outcomes of the repair surgery. Some studies have indicated [15] that there is no significant difference between the timing of repair surgery and the occurrence of postoperative complications. However, we believe that delaying biliary tract repair time may cause prolonged pain for patients and long-term psychological pressure for the surgeon. Accurate evaluation and early repair surgery should be the ideal strategy for the repair of LC-related biliary tract injury. Our results demonstrated that early repair of biliary tract injury in LC with the assistance of 3D visualization technology highlights certain advantages.
A total of 15 patients were diagnosed with postoperative iatrogenic bile duct injury. Despite the initial clinical physicians understanding of bile duct injury degree, referral, and repair preparation factors leading to variability in the timing of early repair surgery, the 15 cases of patients with LC implement biliary surgery to repair a distance interval in 5–28 (14.2 ± 9.7) days. All patients underwent early repair surgery after LC. We believe that the timing of LC postoperative biliary injury repair should consider the classification of bile duct injury, including clinical characteristics such as jaundice, bile leakage, and combined jaundice-type with bile leakage. This helps specialists determine the appropriate timing for the repair operation. Among the 15 patients with primary gallbladder diseases, acute cholecystitis accounted for 53.33% (8/15), and the proportion of patients with bile leakage was 66.66% (10/15). With the assistance of 3D visualization technology, we accurately evaluated the classification of bile duct injury before operation and combined the results of 3D reconstruction during operation to improve the efficiency of bile duct injury opening exploration. All 15 bile duct injury repairs were successful, demonstrating the practical application value of early surgery with 3D visualization assistance.
The 3D visualization technology can intuitively, stereoscopically, and comprehensively evaluate the confluence mode and spatial conformation of hepatic hilar vessels. It can quantitatively evaluate the position of bile duct stenosis, the depth of the hepatic hilar, the rotation angle of hepatic hilar, and the volume of liver segments to determine whether there is liver atrophy. In the preoperative evaluation of early repair of biliary tract injury during LC in this group of 15 cases, compared with abdominal enhanced CT and MRCP, 3D visualization technology proved more intuitive and comprehensive in the evaluation of iatrogenic biliary tract injury. For middle and low bile duct injury caused by transection or stenosis of the common bile duct, 3D visualization technology indicated the location and length of the bile duct injury and its relationship with the main vessels in the hepatic hilar area. In evaluating high-level bile duct injury, the advantages of 3D visualization technology lie in simulating the exposure of the bile duct opening and evaluating the need for perihilar resection. During the bile duct 3D visualization model set-up process, the distribution of bile duct injury after liver hilum biliary tumor and the severity of the biliary injury may have a certain correlation. Biliary tumors of bile leakage are considered to be caused by abdominal cavity fluid accumulation [16]. The higher the biliary injury, the wider the distribution of liver mun biliary tumor, which may extend through the lumen of the lesser omentum (Fig. 3). A multicenter retrospective study also reported [17] a statistically significant correlation between the presence of biliary tract tumors and the severity of bile duct injury (P = 0.02). The correlation of complicated bile duct injuries is eventually a clear diagnosis of Strasberg-Bismuth E3–5 biliary injury risk increased 41.7 times. The existence of biloma affects the intuitive judgment of bile duct injury by abdominal CT or MRCP. By applying the 3D visualization technology to remove the biloma imaging part, we can finally visually display the 3D biliary tract imaging. We believe that the correlation between the distribution of hilar biloma and the degree of bile duct injury needs more refinement and verification of 3D visualization models due to the differences in the effect of abdominal tube drainage during LC.
We reported the experience of diagnosis and treatment of 30 cases of bile duct injury during LC. These cases were retrospectively analyzed with a focus on high-level damage. Among the patients, 15 cases were classified as Strasberg-Bismuth E2 or above of 9 cases of bile duct injury, accounting for 60%. The key to the successful repair of high-level bile duct injury is the exposure of the damaged bile duct opening. This often requires descending or perihilar resection to repair the normal bile duct opening and then complete Roux-en-Y hepaticojejunostomy [18–19]. In clinical practice, 3D visualization technology has been well applied in the perihilar resection of hilar cholangiocarcinoma [20–21]. It is used to evaluate key anatomical landmarks such as point B and point P and to measure the anatomical depth of the hepatic hilum. In early repair surgery for high-level bile duct injury, abdominal infection is relatively aggravated, and tissue edema is significant. This reduces the risk of bleeding in the hilar plate and perihilar resection, resulting in the difficulty of identifying the bile duct opening. However, the preoperative application of 3D visualization technology allows for 3D reconstruction of the primary injury of bile duct opening amount, measurement of the depth of the damaged bile duct openings at the liver door, and appropriate intraoperative decreased liver door or gate resection. Combined with intraoperative bile duct support tube detection or biliary imaging, this approach helps accurately identify bile duct openings, preventing small bile duct opening omissions and causing bile leakage to occur after surgery to repair.
In conclusion, 3D visualization technology is safe and feasible for assisting in the early repair of bile duct injury during LC. The auxiliary effect of 3D visualization technology is primarily highlighted in the two aspects of preoperative evaluation and intraoperative navigation of bile duct injury, offering significant application and promotion value. Recent reports suggested [22] that the LC application of intraoperative indocyanine green biliary imaging can prevent biliary injury and a secondary biliary injury repair surgery [23]. The combination of multiple image techniques and 3D visualization technology may further enhance the prospects for bile duct injury repair surgery.