Suturing for post cholecystectomy bile leaks: a safe and efficient technique

Abstract

Figure 3 When the suturing is finished, a Lapra-Ty® clip is once again applied, eliminating the need for tying an intracorporeal knot. Figure 2 When the suture is passed, the use of pre-applied Lapra-Ty® clip eliminates the need for a knot. Figure 1 A Lapra-Ty® clip is applied to the suture length before inserting into the abdominal cavity. BACKGROUND Bile leak after laparoscopic cholecystectomy occurs in around 0.3–2.7% of patients.1 Re-laparoscopy is a useful diagnostic and therapeutic tool to facilitate identification of the site and nature of the leak, peritoneal lavage and repair. However, after identification of the site of leakage, if control cannot be obtained by application of laparoscopic clips, then laparoscopic suturing of the offending duct (either accessory duct of Luschka or cystic duct stump) is necessary and can be technically challenging, both due to a difficult angle to tie the laparoscopic knot and the ease with which sutures cut through the liver substance. TECHNIQUE We describe a simplified and efficient method for laparoscopic suturing and knot tying in this situation, using Lapra-Ty® absorbable suture clips (Ethicon Endo-Surgery, Caguas, Puerto Rico). A standard port length of 3/0 Prolene is used and a Lapra-Ty® clip is applied extracorporeally to the end of the suture, which is then introduced into the peritoneal cavity. The offending duct is sutured in a standard fashion and a second Lapra-Ty® clip is applied at the end of the suture as an alternative to intracorporeal knot tying. Figures 1–3 show a stylised version of the technique. DISCUSSION This method eliminates the need for intracorporeal knot tying, especially in areas of difficult access, and more importantly permits surgeons to apply the correct tension on tissues to secure control without the suture cutting through the gallbladder bed. The Lapra Ty® clips substitute for knots and also permit the surgeon to apply additional tension if required.2 The clip is composed of absorbable polydioxanone. It maintains tensile strength for 14 days and is completely absorbed by 90 days.2