Major bile duct injury during laparoscopic cholecystectomy

Clinical History

A 27-year-old lady underwent laparoscopic cholecystectomy elsewhere for symptomatic gall stone disease 1 week before. She was referred to us for evaluation of progressive jaundice and unrelenting right upper-quadrant pain. She was febrile on clinical examination and had a bilirubin of 4.8 mg/dl and total leucocyte-count within the normal range.

Imaging Findings

Axial contrast enhanced CT revealed metallic surgical clip in the gall bladder fossa with a moderate sized fluid collection in its vicinity. Tip of the abdominal drain was seen lying little away from the collection. The common duct above the level of the surgical clip was dilated with associated bilobar intrahepatic biliary dilatation. Reformatted CT images revealed the surgical clip lying along the course of the common duct with complete biliary obstruction at this level. These findings suggested the possibility of inadvertent clipping of the common duct with upstream biliary dilatation. The primary biliary confluence was patent.

The present case highlights the role of imaging in evaluating post cholecystectomy complications. The reformatted CT image with noticeable clarity depicts inadvertent clipping of the common duct as the cause of patients’ symptoms following cholecystectomy. Having recognised this grave complication the patient was re-operated and roux-en-Y choledochoenterostomy was performed.

Discussion

Cholecystectomy is one of the most frequently performed abdominal surgeries [1, 2]. Laparoscopic cholecystectomy is considered the preferred treatment for symptomatic gall stone disease replacing conventional open cholecystectomy. Bile duct injury is the most important complication related to the operative procedure of laparoscopic cholecystectomy which can lead to high morbidity, long-term hospitalisation and can be life threatening. Biliary injury during laparoscopic cholecystectomy has been attributed to diverse factors (e.g. complicated gallstone disease in the form of acute cholecystitis or gallstone pancreatitis; aberrant anatomy), and experience of surgeon [3]. Factors inherent to the laparoscopic approach, local anatomical risk factors (fat in the hepatic hilum, or severe chronic scarring of the gallbladder), and inadequate training of the surgeon have also been attributed [1].

Three main clinical scenarios associated with major bile duct injury include: (i) When the operator attempts to clip or ligate a bleeding cystic artery and also clips the common hepatic duct; (ii) When too much traction has been exerted on the gallbladder so that the common bile duct gets tented up and either gets tied off with ligature or clipped; (iii) When anatomic anomalies are not recognised and the wrong structure is divided, for example, when the cystic duct winds anterior to the common bile duct and enters on the left side, or when the cystic duct joins the right hepatic duct rather than the junction of the common hepatic and the common bile ducts [2]. Most of these injuries are recognised in the weeks following laparoscopic cholecystectomy [3]. In contrast, bile duct strictures are the most common of the late complications and can develop a few months to many years after surgery [5]. Ultrasound (US, computed tomography (CT), magnetic resonance cholangiography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are the primary imaging modalities employed to evaluate the biliary tree for post cholecystectomy complications such as strictures, bile leak and/ or residual common duct stones [5]. Traditionally, Bismuth classification is used to classify bile duct injuries and is based on the most distal level at which healthy biliary mucosa (at the proximal site of the injury) is available for anastomosis. There are many newer and much more comprehensive classification systems evolved over the years to classify these biliary tract injuries [6]. These classifications are basically intended to help the surgeon choose the appropriate technique for the repair [6].

Differential Diagnosis List

Final Diagnosis

Inadvertent clipping of the common duct during laparoscopic cholecystectomy

URL:	https://www.eurorad.org/case/9536
DOI:	10.1594/EURORAD/CASE.9536
ISSN:	1563-4086