Getting out of a complex vascular and bile duct injury in an unstable patient

Abstract

Introduction: Bile duct injury during cholecystectomy is a life changing event. Combined vascular lesions most commonly to the right hepatic artery (rHA) are diagnosed in up to 40%, often with a delay in diagnosis. The timing of repair is crucial and also depends on concomitant sepsis. Methods and results: We report on a 82 year old, heavily morbid patient, who had an open cholecystectomy in a district hospital for an acute on chronic cholecystitis. Four days later he had a revision because of bleeding, having received 2 units of blood four days in a row. Two days later he got unwell with sepsis, acute renal insufficiency and a high output bile leak. At time of referral he was ventilated and in an unstable clinical condition. The CT scan revealed free fluid and a transsection of the rHA with peripheral liver necrosis. During emergency laparotomy 2/3 of the central bile duct were necrotic with 4 litres of biliary ascites. To solve this problem and get off the table quickly, 2 biliary tubes were placed in the left and right hepatic ducts, leading the left through a jejunal limb for biliary drainage to allow enterohepatic circulation and fat digestion. The patient recovered gradually and was reconstructed with Roux-Y hepaticojejunostomy without liver resection 7 weeks later, after he lost the drains. He survived both procedures besides pulmonary complications. Conclusion: This easy and fast technique allows patients to recover and gain time for arterial collateralisation for definitive secondary repair.