*Identification and management of biliary leaks before completion of liver resection.* --- ### Overview Assessment for biliary leakage is performed after parenchymal transection to confirm biliostasis and identify exposed or injured bile ducts before abdominal closure. A brief Pringle maneuver may be considered during testing to facilitate pressurization of the biliary system and improve detection of small leaks. >[!info] Clinical Pearl >- A negative leak test does not eliminate postoperative bile leak risk. >- Small peripheral ducts, ischemic injury, and high-risk transection planes may still declare a leak postoperatively. --- ### Assessment Techniques #### Transcystic / Ductal Injection Injection through a cholangiogram catheter allows controlled pressurization of the biliary tree. Common agents: - saline or air (air leak test) - propofol / lipid emulsion ("white test") - ICG fluorescence cholangiography #### Topical Assessment - Hydrogen peroxide applied to transection surface - effervescence creates contrast against the cut surface - may help identify subtle bile staining or fluid leakage --- ### Management of Identified Leaks Goal: controlled closure of identifiable ducts and reduction of postoperative bile leak risk. Options: - directly control identifiable leaking ducts - suture ligation/repair - clips or ligation when appropriate - adjunctive topical agents - sealants / patches - do not replace definitive control of a leaking duct Persistent concern: - consider selective drain placement