Surgical Endoscopy

, Volume 27, Issue 12, pp 4608–4619 | Cite as

ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy

  • A. FingerhutEmail author
  • C. Dziri
  • O. J. Garden
  • D. Gouma
  • B. Millat
  • E. Neugebauer
  • A. Paganini
  • E. Targarona



Several studies seem to indicate at least a 2-fold increase in bile duct injuries (BDI) since the inception of laparoscopic cholecystectomy. Moreover, injuries seem to be more proximal, seem to be revealed earlier, are expressed by leaks more often than by strictures, are repaired more frequently by nonspecialists (either during the index operation or soon after), and appear to be more often associated with loss of substance and ischemia. The plethora of prior classifications probably attests to the evolving clinical spectrum, the mounting wealth of ever-increasing diagnostic methods, and an acknowledgment of insufficiencies or lack of data in earlier classification reports. Previous attempts at uniformity remain incomplete. The purpose of this study was to devise a nominal classification, combining all existing classification items, taking into account the changing pattern of BDI.


Extensive bibliographic research, analysis of each category within the individual classifications combined into one uniform classification.


Fifteen classifications were retained. All items were integrated into the European Association for Endoscopic Surgery (EAES) classification, using semantic connotations, grouped in three easy-to-remember categories, A (for anatomy), To (for time of), M (for mechanism): (1) the anatomic characteristics of the injury: NMBD for non-main bile duct or MBD for main bile duct (followed by a number 1–6, corresponding to the anatomic level on the MBD), followed by Oc (for occlusion) or D (division), P (partial) or C (complete), LS (loss of substance), VBI (vasculobiliary injury in general), and whenever known, the vessel; (2) time of detection: Ei (early intraoperative), Ep (early postoperative) or L (late); and (3) mechanism of injury: Me (mechanical) or ED (energy-driven).


The EAES composite, all-inclusive, nominal classification ATOM (anatomic, time of detection, mechanism) should allow combination of all information on BDI, irrespective of the original classification used, and thus facilitate epidemiologic and comparative studies; indicate simple, appropriate preventive measures; and better guide therapeutic indications for iatrogenic BDI occurring during cholecystectomy.


Bile duct injury Biliary injuries Cholecystectomy Classification Laparoscopic cholecystectomy Laparoscopy Vasculobiliary injury 



A. Fingerhut, C. Dziri, O. J. Garden, D. Gouma, B. Millat, E. Neugebauer, A. Paganini, and E. Targarona have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2013_3081_MOESM1_ESM.docx (120 kb)
Supplementary material 1 (DOCX 121 kb)


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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • A. Fingerhut
    • 1
    • 2
    Email author
  • C. Dziri
    • 3
  • O. J. Garden
    • 4
  • D. Gouma
    • 5
  • B. Millat
    • 6
  • E. Neugebauer
    • 7
  • A. Paganini
    • 8
  • E. Targarona
    • 9
  1. 1.First Department of Surgery, Hippokration HospitalUniversity of Athens Medical SchoolAthensGreece
  2. 2.Section for Surgical Research, Department of SurgeryMedical University of GrazGrazAustria
  3. 3.Surgical Department BCharles Nicolle University HospitalTunisTunisia
  4. 4.Clinical Surgery, Royal InfirmaryUniversity of EdinburghEdinburghUK
  5. 5.Surgical DepartmentAcademic Medical CenterAmsterdamThe Netherlands
  6. 6.Surgical Department, Hôpital St EloiUniversity of MontpellierMontpellierFrance
  7. 7.IFOM FOM–Institut für Forschung in der Operativen Medizin Lehrstuhl für Chirurgische Forschung Private Universität Witten/HerdeckeCologneGermany
  8. 8.Divisione de II Clinica ChirurgicaDipartemento de RomeRomeItaly
  9. 9.Surgical DepartmentSant Pau University HospitalBarcelonaSpain

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