Iatrogenic biliary lesions represent a complex and challenging surgical problem. Large part of these lesions occur during cholecystectomy and these patients are frequently young and generally expect a simple clinical course and immediate recovery.
With the large spreading of laparoscopic cholecystectomy in the last decade, the frequency of iatrogenic lesions of the bile duct have increase dramatically (0,5 %), but the exact incidence of bile duct injury is really unknown, as many cases may go unreported in literature.
Different kinds of bile duct injury are described during cholecystectomy and they have been recently classified by Strasberg in eight types which include also the Bismuth classification of biliary stenosis (Fig. 1, 2).>

Fig. 1: Bismuth classification of benign bile duct strictures based on the location of the lesion in relation to the hepatic duct biforcation.

Fig. 2: Strasberg classification of laparoscopic injuries to the biliary tract. Type A injuries originate from small bile ducts that are entered in the liver bed or from the cystic duct. Type B and Type C injuries are most always involved aberrant right hepatic duct.Type A, C, D, and some E injuries may cause bilomas or fistulas. Type B and other type E injuries occlude the biliary tree and bilomas do not occur.

The  consequence  of  major  biliary  tract  injury include a complex post - operative  course  resulting  in  a lengthy hospital stay with an increased  risk  of  death,  an  excessive  number  of  diagnostic and therapeutic  studies,  frequent re-admissions (often  as  emergencies) and  a  lifelong risk of re-stricture. The costs of these patients remain enormous. Lesion of the bile duct results in high morbidity and mortality rate not only for the immediate consequence but also for the late severe ones:
if they  are unrecognized  or managed improperly, life-threatening complications such as biliary cirrhosis, portal hypertension, and recurrent cholangitis, may develop. A number of predisposing factors have been associated with bile duct injury during cholecystectomy including acute cholecystitis, congenital anomalies of the bile ducts, intra-operative bleeding from the cystic artery or hepatic artery and finally, failure to identify the structures of the triangle of Calot. The majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery: no structure is ligated or divided until it is clearly identified. The proper use of intra-operative cholangiography may identify an impendig injury before the level of injury is extended: early recognition with an immediate conversion to an open procedure and prompt repair can result in a significant decreased morbidity, mortality, length of hospitalization and cost saving ;unfortunately injury is recognized during the laparoscopic procedure only in about 30 % of the cases.
Delayed diagnosis make the treatment more difficult and is responseble of a more complex course: transection of the major bile duct causes bile leakage and may present with external biliary fistula (if a biliary drainage was left in place) or with acute abdomen (choleperitoneum); a complete legation of major bile duct presents with post-operative obstructive jaundice.
A number of alternatives exist (percutaneous transhepatic-endoscopic stenting procedure, surgery repair) for elective repair of bile duct lesions, but the best treatment remains still under discussion. The combined effort of surgeons, endoscopists and radiologists is necessary to optimize the management of patients with laparoscopic cholecystectomy-related biliary complications, so according to us a multi-specialized approach is mandatory for the treatment of more complex iatrogenic biliary lesions.
The complexity of these clinical situations and the possibility of severe consequences need that these patients should treated in highly specialized Centers.