If a bile duct injury is suspected at laparoscopic cholecystectomy, appropriate management includes which of the following?

a.Conversion to open cholecystectomy and intraoperative cholangiography

b.Small ducts (< 3 mm) demonstrated by cholangiography to drain a single liver segment can be ligated

In many cases, proper initial management of a bile duct injury recognized at the time of cholecystectomy can avoid the development of a bile duct stricture. Unfortunately recognition of a bile duct injury is uncommon during either open or laparoscopic cholecystectomy. It must be emphasized that should bile leakage be noted or if "a typical" anatomy is encountered during laparoscopic cholecystectomy, early conversion to an open technique and prompt cholangiography is imperative. If a segment of accessory duct less than 3 mm has been injured, and cholangiography demonstrates segmental or sub-segmental drainage of the injured ductal system, simple ligation of the injured duct is indicated. If the injured duct is 4 mm or larger, however, it is likely to drain multiple hepatic segments or the entire right or left lobe and thus requires operative repair. If the injured segment of the bile duct is short (< 1 cm) and the two ends can be opposed without tension, an end-to-end anastomosis can be performed with placement of a T-tube through a separate choledochotomy either above or below the anastomosis. For proximal injuries, or if the injured segment of bile duct is greater than 1 cm in length, an end-to-end bile duct anastomosis should be avoided because of the excessive tension that usually exists in these situations. The use of Roux-en-Y jejunal limb is preferable for creation of the anastomosis. Regardless of the type of anastomosis, all repairs at the time of initial operation should involve some form of external drainage either with a T-tube or intraoperatively-placed transanastomotic stent.