Intraoperative Cholangiogram Research Articles

Is laparoscopic intraoperative cholangiogram a matter of routine?

Background Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits. Methods Relevant articles in English were identified from the Medline database, and reviewed. Results The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01). Conclusions Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

Laparoscopic Cholecystectomy in Situs Inversus Totalis: A Case Report and Review of the Literature

Situs inversus is an uncommon anatomical variant characterized by transposition of the internal organs. The frequency of cholelithiasis in such patients is similar to that of the normal population. A young woman with situs inversus totalis with symptomatic gallbladder stones underwent a successful laparoscopic cholecystectomy and intraoperative cholangiogram using a mirror-image approach. Her postoperative recovery was uneventful. A review of 21 further cases in the medical literature is presented to address the feasibility of laparoscopic cholecystectomy in situs inversus.

The pitfall of the cystic duct biliary anastomosis in right lobe living donor liver transplantation

Figure 1. (A) Intraoperative cholangiogram obtained by injection of dye through a catheter inserted directly into the incised common bile duct. The patent anastomosis between the recipient common hepatic duct and right lobe posterior segmental system is shown. The cystic duct anastomosis with the allograft anterior segmental biliary system is not visualized. The common bile duct just below the level of insertion of the cholangiogram catheter appears artificially narrowed due to the presence of a suture placed to prevent dye extravasation. (B) Dye through the PTCD showing the obstructed biliary anastomosis between the right anterior segmental ducts and the recipient cystic duct. This image is superimposed on the cholangiogram of the patent right posterior system anastomosis with the recipient common hepatic duct obtained by direct catheter insertion into the common bile duct (see A).

Laparoscopic cholecystecomy in a 16-day-old infant with chronic cholelithiasis

A 16-day-old girl with demonstrated evidence of cholelithiasis was treated initially conservatively on the assumption that the gallstone would resolve spontaneously. However, when repeat ultrasound scan showed a large gallstone and intrahepatic ductal dilatation indicative of antenatal common duct obstruction, the infant underwent laparoscopic cholecystectomy with an intraoperative cholangiogram. The patient did well postoperatively and was on regular feeding by postoperative day 1. An intraoperative cholangiogram showed an impacted stone in the infidibulum of the gallbladder. Gross and histopathologic findings indicated chronic cholecystitis. Based on an extensive review of the literature, this case appears to be the first reported incidence of chronic cholecystitis in a neonate and that of the youngest patient to undergo a laparoscopic cholecystectomy with intraoperative cholangiogram.

Unique features of laparoscopic cholecystectomy in Beta thalassemia patients.

Beta Thalassemia patients suffer from a high incidence of gallstones as well as systemic complications of iron overload. We performed laparoscopic cholecystectomy in 8 beta thalassemia patients and describe their specific features. Diagnosis was based on patients' clinical presentation and sonography. Trocars were readjusted due to the hepatomegaly. No intraoperative cholangiograms were performed. Follow-up included clinical assessment and abdominal sonography. All procedures were completed laparoscopically. Pigment cirrhosis and fibrosis around the cystic duct were noted in all patients. No biliary injury occurred. Post operatively, 4 patients suffered fluid leakage through the trocar site, treated conservatively. No major cardiopulmonary complications occurred. During a mean follow-up time of 65 months, all patients are symptom free and without evidence of biliary lithiasis. Thalassemia patients are difficult and often high-risk patients. Improvement in anesthesia and monitoring enables better management of these patients. Laparoscopic cholecystectomy should be advised in carefully selected thalassemia patients.

Current Management of Common Bile Duct Stones in a Teaching Community Hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.

Laparoscopic cholecystectomy in octogenarians

This study aimed to assess the outcome of laparoscopic cholecystectomy (LC) in patients 80 years old or older. All consecutive patients 80 years old or older who underwent LC for symptomatic gallstone disease were evaluated. Data analysis included patients' age, gender, indication for surgery, comorbid condition, American Society of Anesthesiology (ASA) score, preoperative endoscopic retrograde cholangio pancreatography (ERCP), intraoperative cholangiogram, operative time, conversion to open surgery, morbidity, mortality, and length of stay. In this study, 67 patients (31 men and 36 women) with a mean age of 84 years (range, 80-90 years) were evaluated. Of these 67 patients, 38 (57%) underwent surgery for complicated diseases including acute cholecystitis in 15 patients (22%), gallstone pancreatitis in 17 patients (25%), cholangitis in 3 patients (4.5%), and obstructive jaundice in 3 patients (4.5%). A total of 38 patients (57%) had a preoperative ASA of 3 or 4; 23 (34%) had a preoperative ERCP; and 6 (9%) had intraoperative cholangiogram. The mean operative time was 94 +/- 20 min. Five patients (7.4%) underwent conversion to open surgery because of unclear anatomy. Complications occurred in 12 patients (18%) including pulmonary edema in 3 patients, myocardial infarction in 1 patient, atelectasis in 2 patients, common bile duct injury in 1 patient, urinary tract infection in 2 patients, wound infection in 2 patients, and intraabdominal infected hematoma in 1 patient. The mean length of stay was 5.3 days. There was no mortality. In octogenarians LC is safe and associated with acceptable morbidity and mortality. Therefore, it should be considered for this age group. The relatively high incidence of complicated gallstone disease in this age group may be decreased if surgery is offered to them at earlier stage of the disease, leading to further decrease in perioperative morbidity.

Complete gallbladder and cystic pedicle torsion Laparoscopic diagnosis and treatment

Complete gallbladder torsion is an unusual emergency that requires immediate surgical treatment. Since it was first reported in 1898, <400 cases have been described in the literature, and only three of them were diagnosed and treated by laparoscopic cholecystectomy. Our objective here is to describe an approach that allows a definitive diagnosis and treatment. First we present the case of a febrile 81-year-old woman with acute right upper quadrant pain. Ultrasound showed an alithiasic distended gallbladder with a multilayered wall and a transverse orientation. When exploratory laparoscopy was performed, a gangrenous gallbladder secondary to a 360 degrees clockwise cystic pedicle torsion was found. Laparoscopic decompression, detorsion, and cholecystectomy with an intraoperative cholangiogram were completed. The patient was discharged 72 h later. Next, several preoperative diagnostic methods are reviewed. We conclude that the laparoscopic treatment of this entity is feasible and obviates the performance of unnecessary and nonspecific tests. It offers a favorable and rapid postoperative recovery, in addition to the other well-known advantages of the minimally invasive surgical approach.

Anatomic variation in intrahepatic bile ducts: an analysis of intraoperative cholangiograms in 300 consecutive donors for living donor liver transplantation.

ObjectiveTo describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation.Materials and MethodsThe study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct.ResultsThe anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3).ConclusionThe branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).

Diagnosis of choledocholithiasis and bile duct stenosis by magnetic resonance cholangiogram.

We evaluated the diagnostic accuracy of magnetic resonance cholangiography (MRC) in the diagnosis of bile duct calculi and stenosis. Two-dimensional fast spin echo (FSE) MR cholangiograms were performed using torso multicoil array as a surface coil and respiratory triggering in 50 patients suspected of having bile duct disease. Coronal and axial images were acquired and reviewed prospectively by two radiologists. Direct cholangiographic correlation (endoscopic retrograde cholangiopancreatography [ERCP], intraoperative cholangiogram, percutaneous transhepatic cholangiogram) and surgery were available for comparison and were reviewed by two radiologists. The sensitivity, specificity and accuracy of MRC in diagnosing bile duct dilatation, choledocholithiasis and stenosis were evaluated. It yielded a sensitivity and a specificity of 100% in diagnosing bile duct dilatation. In the diagnosis of choledocholithiasis, MRC yielded a sensitivity of 95%, a specificity and an accuracy of 96%. Bile duct stenosis was diagnosed with a sensitivity and a specificity of 100%. We concluded that MRC exhibited high accuracy in diagnosing bile duct stenosis and choledocholithiasis.

Upper GI 22

Background: Magnetic resonance cholangiopancreatography (MRCP) is a safe and sensitive investigation for the imaging of common bile duct pathology. When used to exclude common bile duct (CBD) stones MRCP may obviate the need for intraoperative cholangiogram (IOC). In this prospective study, we looked at the single centre results of patients who underwent cholecystectomy with IOC following preoperative MRCP. Methods: Over a period of 1 year, 69 patients (24 male and 45 female), mean age 59 (range 19–86) years were investigated by MRCP prior to cholecystectomy. All patients underwent IOC. Inclusion criteria for MRCP consisted of derangement of liver function tests and/or history of jaundice in cases of US proven cholelithiasis. Results: Sixteen (n = 69) had suspected stones or filling defects on MRCP, all but two of these were confirmed to be stones on IOC. In only one patient was a stone visualized on IOC and not seen on MRCP. Conclusions: MRCP may be the only preoperative investigation needed for exclusion of CBD stones, obviating the necessity for intraoperative cholangiogram.

Is intraoperative cholangiography during laparoscopic cholecystectomy cost effective?

Background: Common bile duct injuries occur in 0.2% to 0.8% of laparoscopic cholecystectomies (LC). Intraoperative cholangiograms (IOCG) are a useful means of detecting common bile duct injuries in the operating room. Methods: Data were retrospectively reviewed for patients referred for management of common duct injuries from 1996 to 2000. Cost data were obtained from hospital records. Legal settlements were obtained from published sources. Results: Twenty-one patients (0.133%) were found to have bile duct injuries and incurred median hospital stays of 11.5 days at an average cost of $587,491. The average cost of those requiring reoperation was $669,134. The 21 cases in our sample had total charges of $10,819,767. Performing IOCG during each LC in Orange County would have cost $10,669,725. If extrapolated to state and nationwide levels, the savings is far greater. Conclusions: IOCG during LC is a cost-effective means of preventing the costs of delayed recognition of bile duct injuries.

Cholecystectomy versus cholecystolithotomy for cholelithiasis in childhood: Long-term outcome

Background/Purpose: The presence of cholelithiasis is being reported with increased frequency in childhood. Little is known about the natural history of the disease, and only a few studies have been published regarding long-term results of treated patients. Controversy still exists regarding optimal treatment. Both cholecystectomy and cholecystolithotomy with gallbladder preservation have been recommended as the preferred operative intervention. The purpose of this study was to compare the long-term outcome of cholecystectomy versus cholecystolithotomy for symptomatic gallbladder disease in children. Methods: The charts of all patients with symptomatic cholelithiasis treated in the Dublin Paediatric Hospitals during a 25-year period from 1974 till 1999 were reviewed. Data obtained included age, sex, age at presentation of symptoms, methods of diagnosis, indications for operative treatment, time interval between presentation of symptoms and surgery, surgical technique, performance of a preoperative or intraoperative cholangiogram, stone biochemistry, gallbladder histology, radiologic follow-up, the presence of recurrent or residual stones and symptoms, and the need for reoperation. Patient data were grouped according to method of surgery. All parameters were compared and evaluated. Follow-up was by way of telephone contact with all patients and completion of a questionnaire. Results: There were 18 patients over a 25-year period. Eight patients underwent cholecystectomy, and 10 patients had a cholecystolithotomy. Median follow-up was 2 years in the cholecystectomy group and 5 years in the cholecystolithotomy group. All patients in the cholecystectomy group are asymptomatic and have no recurrent or residual stones on follow-up ultrasound scan. Thirty percent of the patients in the cholecystolithotomy group have recurrent right upper quadrant pain, and 30% show recurrent stones 9.5 months (range, 7 to 12 months) postoperatively. One patient underwent cholecystectomy 8.5 months postcholecystolithotomy. Conclusions: The symptomatic high stone recurrence rate postcholecystolithotomy seen in our series suggest that cholecystectomy is the preferred treatment in patients with symptomatic gallbladder disease. J Pediatr Surg 36:1518-1521. Copyright © 2001 by W.B. Saunders Company.

Laparoscopic exploration of common bile duct: A solution to difficult choledocholithiasis

Objective: To evaluate the role of laparoscopic exploration of common bile duct (LECBD) in the management of common bile duct stone, particularly for patients with failed endoscopic extraction and patients younger than 60 years old.Method: Prospective data of laparoscopic exploration of common bile duct during 1995–1999 were analysed.Results: During 1995–1999, 27 laparoscopic exploration of common bile duct (LECBD) were performed in patients with concomitant gallstone and common bile duct stone, in which half of these LECBD were performed after unsuccessful endoscopic retrieval (13 patients). LECBD was also indicated in patients younger than 60 years old (14 patients) because there was a concern about the potential long‐term complications of papillotomy‐like papillary stenosis and ascending cholangitis. One transcystic duct exploration and 26 choledochotomies were performed. Mean operating time was 138.7 min (70–300 min) and additional procedures included 19 laparoscopic ultrasounds (LUS), three laparoscopic intraoperative cholangiograms (LIOC) and two laparoscopic choledochoduodenostomies. Stone clearance rate was 96% with only one exception. Complications were encountered in nine patients (33%) and one patient died of sepsis subsequent to major bile leak (3.7%). Complications included bile leak/stent migration/collection (4), wound infection (3), minor wound bleeding (1) and self‐limiting postoperative intestinal obstruction (1).Conclusion: LECBD has a high success rate of ductal clearance in patients with ‘difficult common bile duct stones’ despite unsuccessful attempts at endoscopic extraction.

Evaluation of the triangular cord sign in the diagnosis of biliary atresia.

Infantile cholestasis continues to represent a diagnostic challenge. It is very important to diagnose surgically correctable disorders, such as biliary atresia, in a timely manner to prevent progressive damage to the liver. It has been recently suggested that the triangular cord (TC) sign is a simple and useful tool in the diagnosis of biliary atresia. We prospectively studied 65 infants presenting with conjugated hyperbilirubinemia (age range: 32-161 days). All patients underwent ultrasonographic examination with a 7.0-MHz transducer (Acuson, Mountain View, CA). The TC was defined as a triangular, or tubular, echogenic density seen immediately cranial to the portal vein bifurcation. The TC sign was identified in 25 infants, and all of them had histologic features suggestive of biliary atresia; the diagnosis was confirmed at surgery by gross morphology of hepatobiliary system, and liver biopsy, with or without intraoperative cholangiogram. Among the 40 patients who did not have the TC sign, 6 had paucity of the intrahepatic bile ducts. Three had alph-1-antitrypsin deficiency, and 31 had neonatal hepatitis. None of the 40 patients who did not have the TC sign developed acholic stools. Seven patients with biliary atresia were followed by ultrasonographic examination for 6 months after the Kasai procedure. The TC sign disappeared in all patients after the surgery; however, the TC sign reappeared in 3 patients who developed progressive cholestasis after the procedure. The TC sign is a simple, timesaving, and reliable diagnostic tool in the evaluation of infants with infantile cholestasis. The TC sign may also prove to be helpful in following patients after hepatoportoenterostomy. We suggest a new diagnostic strategy for patients suspected to have biliary atresia. When the TC sign is visualized, the patient should undergo intraoperative cholangiogram to confirm the diagnosis of biliary atresia, reserving percutaneous liver biopsy for those patients in whom the TC sign could not be detected.

Villous adenoma of the common hepatic duct

A 78-year-old woman presented with painless jaundice 8 months after laparoscopic cholecystectomy for acute calculous cholecystitis. An intraoperative cholangiogram did not visualize the proximal extrahepatic bile duct. ERCP showed a 2-cm lobulated fixed filling defect within the common hepatic duct distal to the hepatic bifurcation (A). The papilla was in a large peripapillary diverticulum and attempts to obtain a tissue diagnosis were unsuccessful. A cytologic specimen, obtained with a brush by means of a percutaneous approach, was interpreted as containing atypical glandular cells. Biopsy specimens obtained at subsequent percutaneous cholangioscopy showed mucinous debris, degenerative cells, and acute inflammatory fibrous tissue. At exploratory laparotomy, a frozen section biopsy specimen was interpreted as consistent with villous adenoma. The bile duct was resected and a hepaticojejunostomy performed. Histopathologic evaluation of the resection specimen (B) showed a villous adenoma with marked cytologic atypia and rare foci of superficially invasive adenocarcinoma. Five lymph nodes were negative for metastasis. The patient recovered from the surgery and is doing well.

Bile leak from duct of Luschka after liver transplantation.

We report a case of bile leak from an accessory duct of Luschka during cholecystectomy during liver transplantation. Radiological findings suggested that the collection was septated. An intra-operative cholangiogram was obtained by cannulation of the accessory hepatic duct. An infected biloma with Clostridium perfringens was drained surgically. The bile leak that emanated from the gall bladder fossa was found to communicate with an accessory right hepatic duct draining a segmental duct in the right liver lobe. The bile leak resolved completely after direct suture of the accessory duct. Excessive use of electrocautery to the liver bed during donor cholecystectomy may injure subcapsular ducts in the gallbladder fossa. In liver transplantation, dissection should be kept close to the serosal lining of the gall bladder, preserving the areolar tissue in the gall bladder bed, to avoid injury to the duct of Luschka.

The significance of cystic duct stones encountered during laparoscopic cholecystectomy.

Cystic duct stones (CDS) are occasionally encountered during laparoscopic cholecystectomy (LC). They may be noticed during the dissection of the cystic pedicle or seen to extrude from the cystic duct (CD) when it is divided or opened to perform the intraoperative cholangiogram (IOC). The procedures for dealing with CDS range from the simple removal of stones that fall out when the duct is opened to incising the duct over an impacted stone to facilitate its removal or converting to open surgery due to a large stone in a CD adherent to the bile duct (e.g., Mirizzi syndrome). Therefore, we set out to establish criteria that might be predictive of CDS, to examine the technical problems caused by them, to look for the most effective ways of avoiding adverse consequences, especially the risk of missing bile duct stones. We performed a review and analysis of a database that included preoperative, operative, and postoperative data for all patients treated at our hospital who were found to have CDS. In a series of 520 LC performed over a period of 5 years, 64 cases of CDS were documented (12.3%). The preoperative risk factors in 45 of these cases (70.3%) were recent sever acute pain with or without liver function test (LFT) derangement (34.3%), jaundice (14%), pancreatitis (14%), and previous acute cholecystitis (7.8%). At operation, a single stone was found in the CD in 64% of the cases; multiple stones were found in 36%. Dissection of the pedicle was difficult in 21 cases and had to be carried out fundus-first in four cases. The CD was reported to be wide in 18 cases; five of them eventually needed to be closed with endoloops. Operative difficulty was reported in three of 19 cases where there were no preoperative risk factors. Simple removal of the stones was possible in most cases. CDS needed be crushed, the CD incised, or the procedure converted to open in only five cases (7.8%). IOC was attempted in all cases; it was normal in 39 (61%) and failed in two cases (3%). Eighteen patients (28%) were found to have bile duct stones; another five (7.8%) had CBD dilation or debris indicating possible recent passage of stones. Fourteen transcystic and nine direct bile duct explorations were performed. Some CDS may slip from the gallbladder into the CD or the CBD during dissection. Careful retraction and manipulation should therefore be done to minimize this risk. Most CDS are easy to deal with, but some of them can result in increased operative difficulty. If IOC is not carried out on a routine basis, it becomes mandatory if CDS are encountered because 35% of them may be associated with bile duct stones.

Endoscopic retrograde cholangiopancreatography in children: A surgeon's perspective

Purpose: The aim of this study was to review the indications, success rate, and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric age group. Methods: From 1990 to 1999, 21 ERCP procedures were attempted in 20 patients. They consisted of 8 boys and 12 girls whose age ranged from 4 to 17 years (mean, 11.3 years). Fourteen were performed under deep sedation (mean age, 12.8 years), and 7 were done under general anesthesia (mean age, 7.6 years). All ERCP procedures were performed by experienced adult endoscopists. Results: The indication for ERCP was biliary in 15 patients. Eleven had suspected choledocholithiasis by either ultrasound scan, intraoperative cholangiogram or magnetic resonance imaging (MRI). In 6 cases, the ERCP was done for pancreatic pathology. In 11 patients, the ERCP was diagnostic only, and in 10 a therapeutic procedure was done. The overall success rate was 90.5%. Post-ERCP complications consisted of 6 episodes of pancreatitis (28.5%), 4 of which followed a therapeutic procedure, and 1 episode of bleeding. Pancreatitis resolved 2 to 6 days post-ERCP. The patients underwent follow-up between 2 and 56 months after the ERCP (mean, 11 months). Conclusions: The authors conclude that even in experienced hands, ERCP in the pediatric population has a much higher complication rate than in adults (33.3%). We recommend that very specific indications be met before subjecting a pediatric patient to an endoscopic retrograde cholangiopancreatography. J Pediatr Surg 36:733-735. Copyright © 2001 by W.B. Saunders Company.

Spontaneous Perforation of the Bile Duct

We present a classic but rare case of spontaneous perforation of the bile duct in infancy and a previously undescribed treatment technique. The patient, a male age 5 weeks, was admitted with abdominal distention, ascites, and conjugated hyperbilirubinemia. Ultrasound revealed ascites but did not provide visualization of the gallbladder. Although hepatobiliary scintigraphy with technetium [dimethyl iminodiacetic acid (HIDA scan)] showed normal uptake peritoneal excretion suggested perforation of the common bile duct (CBD). Exploratory laparotomy revealed 200 cm3 dark amber ascitic fluid in the peritoneal cavity and cholestasis of the liver. Intraoperative cholangiogram performed via the gallbladder showed a large perforation at the cystic duct/CBD junction. The perforation was large and leakage of contrast prevented demonstration of the distal CBD despite our attempt to primarily repair the perforation. The CBD was explored; a T-tube was placed. T-tube cholangiogram demonstrated flow of contrast into the duodenum. A large leak remained at the cystic CBD junction. A cholecystectomy was performed and a vascularized flap of the gallbladder wall was used to repair the CBD over the T-tube. The T-tube was clamped intermittently beginning 3 weeks postoperatively. T-tube cholangiogram performed 6 weeks postoperatively revealed no extravasation and normal intra- and extrahepatic biliary tree. The T-tube was subsequently discontinued and liver function tests remained normal at 6 months follow-up.