A complex iatrogenic bile duct injury: hilar plate lesion with right hepatic artery section

Abstract

Presenter: Fabio Vergara MD | IPS Universitaria - Servicios de Salud de la Universidad de Antioquia Background: Iatrogenic bile duct injuries remain an important complication in laparoscopic cholecystectomy, which is one of the commonest surgical procedures in the world. There are numerous mechanisms described in the literature as causes of iatrogenic biliary injuries, among them are: undue dissection in a distorted Calot's triangle, use of diathermy close to bile ducts, local pathology such as acute and chronic inflammation with fibrosed gallbladder. Methods: We presented one case of a complex vascular-biliary lesion. A 30-year-old woman was admitted to the emergency room due to abdominal pain in the right hypochondrium and elevated transaminases. Managed by the general surgery group, they requested an abdominal ultrasound that showed acute cholecystitis with cholelithiasis and slight dilatation of the intrahepatic bile duct. Due to intermediate risk of choledocholithiasis, they request MRI that rules out this pathology. She is programmed to perform laparoscopic cholecystectomy. They found slight inflammation with an infudibulus adhered to the hilar plate. They complete the cholecystectomy and notice bile fluid leakage. They request to our group of hepatopancreatobiliary surgery intraoperative evaluation. Evidence of complete injury to the confluence of the liver that anatomically forms a trifurcation, with complete section of the right hepatic artery. Results: Conversion to open surgery was performed and biliary exploration was carried out, finding three ducts separated by more than 2cm from each other, sectioned: anterior branch of right hepatic duct, posterior branch of right hepatic duct, and left hepatic duct. There is an associated right hepatic artery injury without showing its distal end. Patient has an accessory right hepatic artery. It was decided to perform biliary reconstruction in three separate anastomoses (Roux-en-Y hepaticojejunostomy). Conclusion: Bile duct injuries continue to occur globally and can be life threatening. Early detection of the lesion and management by a group of experienced hepatopancreatobiliary surgery can improve the prognosis of patients.