From diagnosis to repair of an E3 + C bile duct injury

Abstract

Background: Common bile duct injury (CBDI) is a rare, but serious, complication of laparoscopic cholecystectomy. Management of these injuries is complex and requires management and surgical treatment tailored to the individual patient. This case describes the presentation, work-up, definition of anatomy, and surgical repair of a Strasberg classification E3 + C biliary injury at the time of laparoscopic cholecystectomy in a patient with aberrant biliary anatomy. Methods: A 61 year old male had a difficult emergency laparoscopic cholecystectomy for acute on chronic cholecystitis. The gallbladder was scarred, shrunken, and there were multiple small stones. One week post-operatively he returned to a peripheral hospital with right upper quadrant abdominal pain. An abdominal computed tomography (CT) scan demonstrated a collection in the gallbladder fossa which was found to be bile, on percutaneous drainage. After source control, the anatomy of the bile duct injury was further defined using magnetic resonance cholangiopancreatography (MRCP), CT angiogram, tube cholangiogram, and endoscopic retrograde cholangiopancreatography (ERCP). To achieve more controlled drainage of the intra-hepatic biliary system, a percutaneous transhepatic biliary-drain (PTBD) was placed into a dilated duct through the right liver into the presumed hilum of the liver. Results: These tests revealed a Bismuth-Strasberg E3 + C-type injury with the IR drain sitting in a biloma at the base of the hilum without concomitant vascular injury. A PTBD was placed in the right anterior duct and tube cholangiogram through the first IR drain demonstrated an additional, low aberrant right posterior duct disconnected from the hilum. An additional PTBD was placed in this right posterior duct for pre-operative drainage and to use for localization intra-operatively. Two months following his original injury, the patient was brought to the operating room for a laparotomy and roux-en-Y hepaticojejunostomy. The drain was used to localize the stump of the hilum. Careful non-circumferential dissection and debridement of the bile duct stump, as well as the aberrant right posterior duct, were performed. A single enterotomy was used to anastomose the right posterior duct (with PTBD across the anastomosis) and the remainder of the hilum with good effect on post-operative cholangiogram. Conclusion: CBDI is a rare complication of laparoscopic cholecystectomy that should be treated in specialized centers with the diagnostic and therapeutic capabilities to control sepsis, define the vascular and biliary anatomy, and plan appropriate surgical repair.