Simultaneous Early Surgical Repair of Post-Cholecystectomy Major Bile Duct Injury and Complex Abdominal Evisceration: A Case Report

Abstract

Background: Major bile duct injuries (BDIs) are hazardous complications after laparoscopic cholecystectomy (0.4%-0.6% of all laparoscopic cholecystectomies) [1, 2-4]. Major BDIs usually require surgery, ideally either within one week or after 3 three months after index surgery [1]. We describe the case of iatrogenic transection of the common bile duct (CBD) complicated by a complex full midline abdominal evisceration presented on day 12 after emergency laparotomy for biliary peritonitis. Case Presentation: A 65-year-old male underwent laparoscopic cholecystectomy in a district general hospital and was discharged on the same day, following apparently uneventful surgery. He, however, re-presented two days later with biliary peritonitis when emergency ERCP showed full CBD transection. The local surgical team performed midline exploratory laparotomy, washout, and external drainage aside the leaking CBD and referred the case to our tertiary HPB service. While awaiting transfer (due to bed shortage), full wound dehiscence occurred. On transfer arrival at our HPB service on postoperative day 11, the patient presented extensive evisceration with loss of domain and persisting high-volume biliary spillage aside bowels. Following assessment and fast literature review, we considered operation undeferrable and planned multi-stage surgeries, including primary Roux-en-Y hepaticojejunostomy (HJ) and progressive abdominal wall closure in multiple sessions under general anaesthesia, aided by vacuum-assisted wound closure and intraperitoneally mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh. Discussion and Conclusion: The complexity of our case lies in the coexistence of 2-weeks biliary peritonitis following early BDI with massive midline evisceration, in combination, both representing over 40% mortality risk, requiring immediate, simultaneous repair. Roux-en-Y HJ and VAWCM have proven safe and effective.