Iatrogenic Bile Duct Injury in 2025: Real World Causes, Referral Patterns, and Reconstruction Outcomes From a Tertiary Care Centre in a Sub-himalayan Region.

Background Despite widespread adoption of laparoscopic cholecystectomy (LC), major bile duct injuries (BDIs) continue to occur, particularly in real-world, resource-limited settings. Methods This retrospective study analysed a prospectively maintained BDI-benign biliary stricture registry at the hepatopancreatobiliary (HPB) and gastrointestinal (GI) surgery unit of Indira Gandhi Medical College (IGMC), Shimla, a tertiary HPB referral centre in the sub-Himalayan region. All adult patients referred between January 2020 and December 2024 with major iatrogenic BDI requiring definitive surgical reconstruction were included. Minor biliary injuries managed conservatively or endoscopically were excluded. Demographic data, injury characteristics, surgeon experience, referral patterns, management, and outcomes were evaluated. Results Twenty-three patients underwent Roux-en-Y hepaticojejunostomy for major BDIs. Most injuries occurred during LC (91.3%) and were associated with difficult gallbladder anatomy (73.9%). Seventeen injuries (73.9%) were caused by surgeons with less than three years of post-training experience (p = 0.028). Primary repair was attempted at the index centre in 43.5% of patients, frequently in high-grade injuries. Referral beyond 72 hours occurred in 91.3% of cases. Three additional patients with catastrophic vasculobiliary injury died before reconstruction. All reconstructed patients had favourable medium-term outcomes. Conclusion Major BDI remains largely preventable. Early referral, avoidance of unsafe repair, adoption of bailout strategies, structured early-career supervision, and improved infrastructure are essential to reduce preventable morbidity and mortality.