Bile Duct Injury Following Cholecystectomy: Diagnosis, Timing of Repair, And Surgical Reconstruction

Abstract

Iatrogenic bile duct injury (BDI) remains one of the most serious complications of cholecystectomy. Although uncommon, BDI may result in bile leakage, biliary peritonitis, sepsis, obstruction, recurrent cholangitis, anastomotic stricture, secondary biliary cirrhosis, and repeated interventions. Outcomes are influenced by the timing of recognition, effective source control, complete definition of biliary and vascular anatomy, preservation of ductal blood supply, and access to an experienced hepatopancreatobiliary (HPB) team. This narrative review synthesizes evidence published between 2022 and 2026 regarding epidemiology, mechanisms of injury, classification, diagnosis, endoscopic and percutaneous management, timing of definitive repair, and surgical reconstruction. Minor injuries with preserved ductal continuity are frequently amenable to endoscopic decompression and selective stent placement. Major injuries, particularly Strasberg type E lesions, most commonly require bilioenteric reconstruction, with Roux-en-Y hepaticojejunostomy representing the most established reconstructive option. Contemporary evidence supports favorable outcomes after both carefully selected early repair and delayed reconstruction; however, the 2025 SAGES-AHPBA guideline conditionally favors definitive repair after 6 weeks when the clinical setting permits. Across contemporary series, favorable long-term outcomes are consistently associated with early referral to specialist HPB centers, adequate control of sepsis and bile collections, and construction of a wide, well-vascularized, tension-free mucosa-to-mucosa anastomosis. Long-term surveillance is essential because biliary strictures may develop years after reconstruction.