Introduction Before the advent of laparoscopic procedures in the late 1980s, open cholecystectomy was the prevalent mode of treatment for gall-stones. 1 As the surgeons were getting used to the basics of minimal intervention, their inexperience and lack of familiarity with telescopic interpretation of biliary anatomy resulted in a significant number of bile duct injuries. 2 While the incidence of the later complication was around 0.1-0.3%, with the open approach, 3-7 a higher risk of injury - almost 2% was related to laparoscopic cholecystectomies. With the growing experience of laparoscopic surgeons and availability of better operating instruments, the rate of iatrogenic bile duct injuries has now dropped to < 0.5%. 4- 7 and the procedure is now accepted as the treatment of choice for symptomatic gallstones. Surgeons now readily adopt on laparoscopic approach even for acute cholecystitis which was previously viewed as a relative risk owing to excessive dissection in the Calot's Triangle and inadvertent use of diathermy for associated bleeding, resulting in bile duct damage. 8 The presence of chronic adhesions secondary to recurrent attacks of cholecystitis, morbid obesity and presence of anomalous duct or vessels can render the procedure somewhat challenging and difficult. 9 Biliary injuries associated with either the laparoscopic or open approach include leaks, strictures, transaction or ligation of major biliary ducts. 8 Magnetic resonance cholangiopancreatography (MRCP) is the most sensitive and accurate test frequently used for the diagnosis of complications of cholecystectomy even though percutaneous transhepatic cholangiography (PTC) can better delineate certain complications, e.g. common bile duct (CBD) strictures. 10 Other investigations in use are endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography. Intra-operative cholangiography J Pak Med Assoc 1008 ORIGINAL ARTICLE Surgical management of bile duct injuries following open or laparoscopic cholecystectomy Ainul Hadi, 1 Zahid Aman, 2 Shehzad Akbar Khan, 3 Humera Zafar, 4 Mazhar Khan, 5 Shahid Khan Afridi, 6 Zafar Iqbal 7 Abstract Objective: To evaluate the management of bile duct injuries following open and laparoscopic cholecystectomy in a tertiary care hospital. Methods: The descriptive case series was conducted from July 2002 to June 2008 at Hayatabad Medical Complex Peshawar, Pakistan. A total of 32 patients who sustained extra hepatic bile duct injuries during open and laparoscopic cholecystectomy were included. Patients having hepatobiliary malignancy or those managed through endoscopic retrograde cholangiopancreatography and stenting were excluded. Patients were thoroughly investigated including to reach a final diagnosis, and were followed up for 02 years. Results: The mean age of patients was 45.4±2.7 years with a female preponderance (M:F=1:9.7). The time of presentation was up to 03 months after initial surgery. Seven (21.87%) patients sustained bile duct injury during laparoscopic cholecystectomy, while 25 (78.13%) sustained injury during open procedure. Abdominal ultrasound scan was performed in 29 (90.63%) cases, endoscopic retrograde cholangiopancreatography in 14 (43.75%) and magnetic resonance cholangiopancreatography in 26 (81.25%) cases. Eleven (34.37%) patients had common bile duct leak, 9 (28.13%) had common hepatic duct injury, 9 (28.13%) had CBD strictures and 3 (09.37%) had injury to the biliary tree at porta hepatis level. Operative procedures performed included Roux-en-Y hepaticojejunostomy in 19 (59.38%) cases, choledochoduodenostomy in 7 (21.88%) cases, Roux-en-Y portoentrostomy and primary repair in 3 (09.37%) cases each. Postoperative morbidity included recurrent cholangitis 9 (28.12%), wound infection 4 (12.50%) and bile leakage 2 (06.25%). Hospital stay ranged 08-16 days. Hospital mortality rate was 03.13%, (n=1). Conclusion: The most frequent site of bile duct injury during open and laparoscopic cholecystectomy was the common bile duct, and Roux-en-Y hepaticojejunostomy was the procedure of choice by experienced surgeons for the management of such injuries. Keywords: Cholecystectomy, Bile duct injury, Roux-en-Y hepaticojejunostomy. (JPMA 63: 1008; 2013) 1 Department of Surgery, 2,3,5 Department of Surgery, Khyber Girls Medical College, 6,7 Surgical Unit, Hayatabad Medical Complex, Peshawar, 4 Department of Surgery, CMH, Rawalpindi. Correspondence: Ainul Hadi. Email: surgeonhadi05@yahoo.com