Medically induced bile duct injury is a common surgical complication in biliary surgery, which, if mishandled, may require multiple surgical repairs, with catastrophic consequences for the patient, his family, the physician, and the hospital [1]. With the popularization of laparoscopic cholecystectomy, the incidence of medically induced right posterior hepatic bile duct injury is on the rise. From May 1990 to May 2008, 35 cases of right posterior hepatic bile duct injury of medical origin were admitted to our hospital, and all of them were cured after active treatment. 1. Clinical data: Among the 35 cases in this group, 15 cases were patients in our hospital and 20 cases were referred from outside hospitals; 14 cases were male and 21 cases were female; ages ranged from 20 to 65 years old (41.5±6.5 years old). Preoperative diagnosis was stone cholecystitis in 28 cases, stone cholecystitis with choledochal stones in 4 cases, and gallbladder polyps in 3 cases. Surgical procedures: laparoscopic cholecystectomy in 25 cases, open cholecystectomy in 6 cases, open cholecystectomy + choledochotomy in 4 cases. Intraoperative findings were found in 8 cases, which showed postoperative clinical manifestations mainly bile leakage and cholestatic peritonitis. 27 cases of postoperative findings in this group showed bile leakage, which was found from 1 to 15 days after operation, and the amount of bile leakage ranged from 600 to 5,000 ml, and 15 patients showed the more typical manifestations of cholestatic peritonitis, such as abdominal pain, abdominal muscle tension, and pain in the abdominal region. The other 12 patients showed mainly abdominal distension and progressive aggravation without obvious abdominal pain and abdominal muscle tension, etc. Fluid accumulation in the abdominal cavity was found in 27 patients by ultrasound, CT and other imaging examinations. According to the cause of injury, the right posterior hepatic bile duct injuries in this group were categorized into three types, namely, Type I: 6 cases of stabbing or laceration of the right posterior hepatic bile duct; Type II: 15 cases of thermal injury (electrical burns); and Type III: 14 cases of ligature transverse injuries (Figure 1). Figure 1 Classification of right posterior hepatic bile duct injury Class Ⅰ: puncture wound or laceration of right posterior hepatic bile duct Class Ⅱ: thermal injury (electrocautery) Class Ⅲ: ligature transverse injury 2. Results: 6 cases of Class Ⅰ injuries in this group were found in 2 cases during the operation, 1 of which was only locally patched with ordinary round needle and thread without support drainage, and bile leakage was observed in the patient on the 10th day after the operation with the accumulation of 2,000 ml of bile in the abdominal cavity, and the abdomen was opened again to place the 12-gauge T-tube. A 12-gauge T-tube was placed in the abdomen again to support the bile duct of the right posterior lobe of the liver, and the patient was cured by repairing it with a 0/5 non-invasive silk thread. In another case, the patient was found to have a bile leak on the 10th day of operation, and was cured by using 0/5 non-invasive wire to repair the bile duct of the right posterior lobe of the liver and a ureteral catheter to support the bile duct of the right posterior lobe of the liver. 4 patients found to have bile leaks were re-opened and probed again on the 1th, 2th, 3th, and 5th day of operation, and were found to have accumulated 600~3000 ml of bile in the abdominal cavity, which was sucked up and then rinsed out with a large amount of physiological saline, 3% hydrogen peroxide, and 1:10 dilute iodine solution, which decreased the occurrence of post-operative intra-abdominal infections. To minimize the occurrence of postoperative intra-abdominal infections. A saline pad containing 50% dextrose liquid was used to apply wet compresses to the right subhepatic space to reduce tissue edema. After finding the bile duct injury in the right posterior lobe of the liver, the common bile duct was opened, and a ureteral catheter or a 12-gauge T-tube was placed across the arm from the common bile duct to the far side of the right posterior lobe of the liver where the bile duct was injured; the bile duct at the injury was closed with interrupted stitches using 0/5 or finer vascular sutures, and the bile duct at the injured place was injected with water to test that there was no leakage, and then it was covered with a large omental membrane or a medical bio-gel and drained in the subhepatic space. The subhepatic hiatus was placed for drainage, and the biliary drainage tube was supported for 9 months to 1 year after the operation. These 4 patients had good postoperative recovery after the above treatment. In this group, there were 15 cases of class II injuries, none of which were found during the operation, and all of which developed bile leakage after the operation. They were re-examined surgically from the 5th to the 15th day after the operation respectively, and it was found that all of them were perforated at the bile duct cauterization of the right posterior lobe of the liver. After treatment of cholestatic peritonitis according to the above methods, the inactivated tissues at the bile duct burns were removed. In 10 patients, the bile duct of the right posterior lobe of the liver had a large extent of damage, exceeding 1/2 of the diameter of the duct, which was easy to cause bile duct stenosis in the later stage of the operation due to direct suture, therefore, the bile duct of the right posterior lobe of the liver was anastomosed to the end side of the paracolic hepatic duct and the anastomotic port was built-in to support tube to drain, and the postoperative recovery was smooth. In 2 patients, the hepatic round ligament was used to repair the defective right posterior hepatic bile duct, and satisfactory results were obtained. In the other 3 patients, the defective right posterior hepatic bile duct was too large to be repaired or anastomosed by the above methods. Therefore, after finding the right posterior hepatic bile duct, a silicone tube or ureteral catheter with an appropriate diameter was inserted into the lumen of the right posterior hepatic bile duct, fixed properly, and drained externally from the catheter, and then the catheter was clamped off about 3 months after the operation, and then a bile-intestinal Roux-Y endobiliary drainage procedure was carried out after the right posterior hepatic bile duct was dilated to 0.6 cm. Roux-Y internal bile-intestinal drainage was performed again after the right posterior lobe of the liver was dilated to about 0.6 cm, and more satisfactory curative effects were achieved. In this group, there were 14 cases of class III injuries, 6 cases were found intraoperatively, all of them were transverse injuries, and the right posterior lobe of the liver bile duct and the paracolic common hepatic duct were anastomosed end to end immediately, and they recovered well after the operation. The other 8 cases were re-examined 3 to 8 days after surgery, and 3 cases were found to be transverse injuries, and end-to-end anastomosis between the right posterior hepatic bile duct and the paracolic common hepatic duct was performed with good results. The other 5 cases had large defects after right posterior hepatic bile duct injury, so they could only use the aforementioned method of first placing a tube to drain, and then bile and intestinal drainage at a later stage, and the results were satisfactory. 3.1 Causes of right posterior hepatic bile duct injury of medical origin Clinically, the variation of right posterior hepatic bile duct is relatively common, and after a long-term clinical research in our hospital, we found that it is manifested as the bile duct of the right anterior lobe of the liver joins with the paracolic bile duct to form the “paracolic duct”, and the bile duct of the right posterior lobe of the liver joins with the paracolic duct to form the common hepatic duct outside of the liver, which can be divided into three types, i.e., type I. There are three types, i.e., type I: the cystic duct opens into the common bile duct, and the right posterior hepatic bile duct joins the common parahippocampal duct proximal to the opening of the cystic duct; type II: the cystic duct opens into the posterior hepatic bile duct or the posterior hepatic bile duct opens into the neck of the gallbladder; and type III: the cystic duct opens into the common hepatic duct, and the posterior hepatic bile duct joins the common bile duct farther away from the cystic duct opening; type II is the most common type, accounting for about 40% of the cases (Fig. 2) [3]. Operators who are unfamiliar with these anatomical variants are prone to intraoperative injury. In cases of acute cholecystitis with highly edematous and congested choledochal cystocele, it is even more difficult to identify the abnormal anatomy, increasing the risk of surgery. In our group, there were 16 cases of right posterior hepatic bile duct injuries that occurred in the presence of significant gallbladder inflammation and unclear anatomical relationships. In laparoscopic cholecystectomy, the dissection of the gallbladder triangle should be performed cautiously with an electric knife, close to the jugular abdomen of the gallbladder, and small pieces of tissue should be cauterized in short bursts to avoid the formation of thermal injury to the bile duct of the posterior lobe of the right liver by cauterizing the tissues in large pieces. Do not easily cut duct-like structures when there is difficulty in defining anatomic relationships. The basic principle of avoiding medically induced right posterior hepatic bile duct injury is that the operator must have a high sense of responsibility and rich experience in biliary surgery, and strictly follow the three-word principle of “defense – cut – defense”. Figure 2 Variations of the right posterior hepatic bile duct Type I: the cystic duct opens into the common bile duct, and the right posterior hepatic bile duct converges into the paracolic duct proximal to the opening of the cystic duct; Type II: the cystic duct opens into the right posterior hepatic bile duct or the right posterior hepatic bile duct opens into the neck of the gallbladder; and Type III: the cystic duct opens into the common hepatic duct, and the right posterior hepatic bile duct converges into the common bile duct farther away from the confluence of the cystic duct. 3.2 Clinical manifestations of right posterior lobe bile duct injury If bile leakage is found in the gallbladder triangle during gallbladder resection, the operator should pay great attention to it and carefully search for the cause of the bile leakage in order to find out the injury of right posterior lobe bile duct as early as possible. If abdominal pain, abdominal distension, peritonitis and other manifestations occur after surgery, the patient should be alerted to the existence of bile leakage, and timely imaging examination can be carried out, and if necessary, ultrasound-guided peritoneal puncture can be carried out, and if bile can be extracted, it will have a decisive value for the diagnosis. The appearance of bile leakage after bile duct thermal injury is often late, and clinical attention should be paid to the differentiation. In particular, we found that about 34.3% (12/35) of the patients mainly showed increasing abdominal distension without obvious abdominal pain, abdominal muscle tension and other manifestations of peritonitis, but the patient’s intra-abdominal bile accumulation amounted to 1,500 to 5,000 ml, which we called atypical biliary peritonitis, and we must prevent the patients from being blinded by the milder symptoms and signs. 3.3 Management of right posterior hepatic bile duct injury Depending on the type of injury and the time of repair surgery, appropriate surgical methods should be used. If the right posterior lobe bile duct is stabbed or lacerated, and the range is less than 1/2 of the diameter of the duct, the bile duct can be directly sutured at the bile duct injury, and the bile duct of the right posterior lobe of the liver can be supported by a built-in tube. The technical points are as follows: ① Use 0/5 or finer vascular suture for suturing to prevent bile leakage from the needle eye after surgery. ② Intermittent suture under direct vision to close the injury, after the anastomosis is completed, carefully check whether there is a bile leakage and bile duct wall ischemia; ③ Select the No. 12 T-tube or ureteral catheter as the support material, one end of which should be placed into the right posterior lobe of the liver bile duct and reach the bile duct repair to the far end of the bile duct, and the other end of the bile duct from the common bile duct to lead out; ④ support time of 9 to 12 months, too early to pull out of the tube is prone to lead to bile duct stenosis. In this group, there is a case of intraoperative bile duct damage found after using ordinary silk suture, as a result of postoperative bile leakage and had to be repaired again, with 0/5 non-invasive thread repair bile duct cure, the lesson is very profound. After thermal injury of the bile duct, the inactivated bile duct wall should be removed from the burned area during repair, resulting in a larger scope of the injury. In addition, the diameter of the bile duct of the posterior lobe of the right liver is only about 3 mm, and direct suturing is likely to result in postoperative bile duct stenosis. Therefore, for this type of injury and transection of the right posterior hepatic bile duct, end-to-end anastomosis of the right posterior hepatic bile duct with the paracolic common hepatic duct or hepatic round ligament repair can be used. The advantage of this type of surgery is that the normal biliary physiological channel is maintained, but the technical requirements are high, and the essentials are: ① use fine vascular sutures; ② anastomotic tension should not be too large; ③ interrupted suture or continuous posterior wall suture, anterior wall interrupted suture method; ④ anastomosis built-in support tube drainage, from the common bile duct drainage; ⑤ support time of 9 to 12 months. In our group, 21 patients underwent repair surgery using the above methods with good results. If the extent of bile duct injury is large or the bile duct of the posterior lobe of the right liver is resected and cannot be anastomosed end-to-end with the paracolic duct, and the patient has a large amount of bile leakage or is combined with a more serious intra-abdominal infection, the repair surgery should be carried out in two stages. In the first stage, after entering the abdomen, the bile and infected necrotic tissues were removed from the abdominal cavity, and all the jejunum and ileum were pulled out of the abdominal cavity, and the abdominal cavity was cleaned with a large amount of saline, 3% hydrogen peroxide, and 1:10 complex iodine solution, which reduced the absorption of the inflammatory factors and toxins, and effectively prevented the formation of intra-abdominal abscess in the postoperative period. Then a saline pad containing 50% glucose solution was used to wet compress the right subhepatic space to reduce tissue edema and facilitate surgical operation. After finding the bile duct severed end of the right posterior hepatic lobe, a silicone tube or ureteral catheter of the appropriate size was placed according to its diameter, properly fixed and then led out of the abdominal wall. The common bile duct was opened and the T-tube was placed. A rubber tube was placed in the right subhepatic space for drainage to complete the one-stage surgery. After 3-6 months of operation, the bile duct drainage tube of the right posterior lobe of the liver can be clamped to make it dilated. When the bile duct of the right posterior lobe of the liver is dilated to 0.6-0.8 cm and there is no abscess in the right hepatic hiatus, it is feasible to perform the second-stage repair surgery, and the operation style is right posterior lobe of the liver and the bile duct of the jejunum Roux-Y endoluminal drainage. Surgical points: ① use 3-0 non-invasive thread as suture material; ② make bile duct-jejunum end-lateral anastomosis, avoid end-to-end anastomosis and result in postoperative anastomotic stenosis; ③ make bile-intestinal layer of intermittent exostoses, the knot is played on the outside of the anastomosis, to keep the anastomotic inner wall smooth, to avoid the formation of the anastomotic curtains; ④ the anastomotic wall is smooth, and the anastomotic curtain is not formed; ④ the anastomotic wall is not formed. “The anastomosis was not twisted, and the tension was appropriate; ⑤ the anastomosis had a built-in T-tube for drainage, and the transverse arm of the anastomosis reached the bile duct of the right posterior hepatic lobe far away from the anastomosis, while the straight arm drained out from the jejunum of the bridging collaterals, and the tube was brought in about 3 months after the operation; ⑥ synchronous suture of the jejunum of the bridging collaterals and the proximal jejunum was done in 10 cm, which reduced the occurrence of postoperative regurgitant cholangitis. Eight patients in our group had good results after the above two-stage surgical treatment.