Penetrating abdominal trauma due to gunshot is a critical and often life-threatening condition that requires prompt diagnosis and management. Among the structures affected in such injuries, the biliary system is rarely involved due to its deep location. Injury to the common bile duct is particularly uncommon and represents a difficult surgical challenge due to its anatomical position.^[10,11] The limited number of patients and studies in the literature highlights that treatment modalities are often tailored specifically to the patient, and there is no established consensus.

In our case report, an exploratory laparotomy was performed on a patient with peritonitis and hemorrhagic fluid detected in the abdominal cavity on imaging, along with a liver injury. Following hemostasis, dissection of the hepatoduodenal ligament was carried out due to suspected injury in this area. The portal vein and hepatic artery were found to be intact, while an isolated CBD injury was identified.

In a meta-analysis conducted by Pereira et al.^[12] in 2019, it was reported that deep liver laceration, intra-abdominal bile, hematoma of the porta hepatis, or bile-stained porta hepatis could be used as indicators for identifying bile duct injury in patients undergoing laparotomy. In the presence of these indicators, it was recommended that the surgeon suspect bile duct injury and consider diagnostic approaches such as intraoperative cholangiography, Kocher’s maneuver, or extensive dissection of the porta hepatis. Due to the presence of an injury near the hepatic hilum in our patient and damage to the hepatoduodenal ligament, we deemed hepatoduodenal ligament dissection to be appropriate. This approach allowed us to identify the CBD injury effectively.

Following the identification of CBD injury, various repair approaches are available. In a case report from Taiwan presenting four cases of extrahepatic bile duct injury, it was reported that a patient with CBD injury due to penetrating abdominal trauma underwent primary repair with T-tube choledochostomy, and no additional complications were observed during follow-up. Additionally, the same study compiled results from studies conducted between 1985 and 1996 evaluating patients with bile duct injuries caused by trauma. Among a total of 75 patients, 35 underwent primary repair with T-tube choledochostomy, 18 underwent hepaticojejunostomy, 5 underwent liver resection, and 1 underwent the Whipple procedure. Among the patients treated with primary repair and T-tube choledochostomy, 7 experienced biliary morbidity, and 6 had mortality, whereas among those who underwent hepaticojejunostomy, 5 had biliary morbidity, and 1 had mortality. The study concluded that while no significant differences were found between treatment modalities, early diagnosis and injury-specific treatment selection were emphasized as crucial factors.^[4] In our patient, following hepatoduodenal ligament dissection, near-complete transection of the CBD was observed, leading to complete transection being performed. The patient subsequently underwent Roux-en-Y hepaticojejunostomy.

While reviewing the literature, studies show that it is evident that the surgical technique for CBD injuries should be selected based on the type of injury. For incomplete transections, techniques such as primary repair, primary repair with T-tube placement, or end-to-end anastomosis with T-tube placement have been described. In cases of complete transections, surgical options include end-to-end anastomosis with T-tube placement, end-to-end anastomosis, or hepaticojejunostomy. Following T-tube applications, biliocutaneous fistula formation is a common complication, while stricture formation is frequently observed after primary repair and end-to-end anastomosis of the bile duct. For this reason, hepaticojejunostomy is recommended as the preferred surgical treatment for CBD injuries.^[13-15]

Non-surgical treatment approaches for extrahepatic bile duct injuries caused by penetrating trauma have been reported in the literature. Kleiner et al.^[16] described a case in which a hemodynamically stable patient with a bile duct injury from a stabbing was successfully treated with endoscopic stenting. After duodenal repair and hemostasis during laparotomy, the patient developed bile leakage in the postoperative period, confirmed by a HIDA scan. The injury was managed with ERCP and intracholedochal stenting. The patient recovered without complications, with the stent removed two months later and the biliary system found to be intact.

In patients with penetrating right upper quadrant injuries managed with selective nonoperative observation, where bile duct injuries are detected during nonoperative follow-up, or in cases where bile duct injuries are not identified during laparotomy but biliary pathology is observed in the postoperative period, some studies have shown that endoscopic treatment methods are successful in 90-95% of cases.^[17-19] Therefore, in these patients, diagnostic methods such as magnetic resonance cholangiography with gadoxetic acid disodium, HIDA scan, ERCP, or even diagnostic peritoneal lavage can be used to determine the nature of intra-abdominal fluid if present.^[12,20] In patients treated with endoscopic stenting, the risks of complications such as bile leakage, stent migration, and the need for a second invasive intervention should be kept in mind.^[21,22]