Common Bile Duct and Pancreatic Injury After Laparoscopic Adrenalectomy

Abstract

Introduction: Over the last 2 decades, laparoscopic procedures have become the gold standard for the majority of surgical treatments due to the benefits of the minimally invasive approach. Complications with laparoscopic procedures are minimal and uncommon, however, they do include pancreatic and common bile duct injury. We present a case in which our patient suffered both pancreatic and CBD injury after undergoing left laparascopic adrenalectomy managed successfully by interventional radiology and gastroenterology. A 73-year-old female with a history of hypertension, diabetes melitus, dyslipidemia, and CAD was admitted for laparoscopic left adrenalectomy, indicated in the diagnosis and treatment of an incidental, expanding 2.2-cm heterogenous left adrenal mass found on abdominal computed tomography (CT). A Blake drain was placed during the procedure after the presumption that the separation of the left adrenal gland caused injury to the tail of the pancreas. She was discharged on post-op day 2 with no complications. Two weeks later, she developed increasing greenish discharge from the drain, after which she underwent ERCP showing proximal pancreatic duct disruption with extravasation with communication to the distal CBD. Placement of a pancreatic duct stent was followed. The patient continued to have abdominal pain with elevated liver function tests, in which IR was then consulted for percutaneous biliary drainage and rendezvous stenting of the CBD. The patient’s hospital course was then complicated by bacterial sepsis and was intubated for respiratory failure. A second drain was then placed by interventional radiology in the retroperitoneal space due to accumulation seen on imaging. Her clinical status improved and she was subsequently extubated and discharged to rehab. Iatrogenic CBD and pancreatic injury are exceedingly uncommon especially in the setting of laparascopic surgery. An extensive literature search revealed no reported cases in which both have taken place. A large study of transperitoneal laparoscopic urologic procedures found that CBD injuries occurred in only 2 out of 2,866 cases. Moreover, it is noted that injury of the pancreatic tail secondary to left nephrectomy or adrenalectomy occurred in only 0.69% of cases. The patient was also successfully managed by the joint efforts of IR and GI without requiring open surgery. This collaborative approach has changed the frontier of managing patients with what use to be all surgical cases. Clinicians should be aware of this entity and despite the low risk of laparoscopic surgery, there are complications that can be potentially fatal and multidisciplinary management has shown to be of great value.