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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_907_Библиотеки_им_академика_М_И_Перельмана
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events on the patient.
Complications common to any laparoscopic procedure
should always be considered when evaluating the patient
with abdominal pain following laparoscopic
cholecystectomy. Inadvertent injury to bowel from trocar
placement or instrument passing may present with
peritonitis and postoperative sepsis. Evidence of urinary
tract or surgical site infection should be queried.
Constipation or ileus may also be seen in some patients,
but lack of return of bowel function should lead to
consideration of a more serious underlying complication.
The major complications specific to laparoscopic
cholecystectomy include postoperative hemorrhage, a
retained common bile duct stone, and bile duct injury.
Bleeding complications following cholecystectomy are rare
and often present in the first 24 to 48 hours postoperatively.
Common etiologies include hemorrhage from the cystic
artery stump or liver parenchyma along the gallbladder
fossa. A retained common bile duct stone may present
days to weeks following cholecystectomy and is typically
associated with signs and symptoms of obstructive
jaundice, cholangitis, and/or pancreatitis. Bile duct injury
represents the most feared technical complication of
cholecystectomy and can present in protean ways
dependent on whether the primary i njury results in a biliary
leak or obstruction. Maintaining a high index of suspicion
for bile duct injury in patients with unexpected problems
following cholecystectomy is essential to making an early
and definitive diagnosis. Sending a patient with unusual
postoperative pain home from the clinic or emergency
room without proper assessment can have catastrophic
consequences if underlying intra-abdominal sepsis or
biliary obstruction is left to go unaddressed.
Workup
Evaluation of the postcholecystectomy patient with
suspected complications should proceed in a methodical
manner. Initial maneuvers include administration of
appropriate analgesia and fluid resuscitation as indicated.
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Laboratory evaluation should include a complete blood
count, metabolic panel, liver profile, amylase, lipase,
coagulation profile, and urinalysis. The initial laboratory
results can be helpful in guiding the selection of appropriate
imaging procedures and other interventions. Laboratory
evaluation may initially be underwhelming, though a
leukocytosis may be present. The total bilirubin may be
normal or only slightly elevated (2 to 4 mg/dL) in the case of
a complete biliary transection with free leak. Reabsorption
of bile from the peritoneum may elevate the bilirubin slightly.
Marked elevation of the transaminases is not typical and
should raise concern of an associated vascular injury when
present. Biliary injuries are typically not associated with
abnormalities of the serum amylase and lipase. When
associated with an obstructive pattern to the liver profile,
biochemical evidence of pancreatitis may indicate a
retained common bile duct stone rather than a bile duct
injury.
Ini tial diagnostic imaging may include ultrasound, to
assess for perihepatic fluid collections and biliary ductal
dilatation, or computed tomography (CT) in select patients.
If identified, significant perihepatic collections may be
percutaneously drained. If bi lious, a biliary leak is
diagnosed, and the evaluation should proceed with direct
cholangiography either by endoscopic retrograde
cholangiography (ERC) or percutaneous transhepatic
cholangiography (PTC). If the fluid visualized on ultrasound
or CT is not easily drained, or if the question of a biliary
injury is still open, a hepatobiliary iminodiacetic acid (HIDA)
nuclear medicine scan may be performed. HIDA scans can
detect extravasation of biliary drainage and may also
demonstrate failure of bile excreted from the liver to enter
the duodenum. Further anatomic detail is not available from
HIDA scans, but the test may be sufficient to confirm a
suspicion of bi liary injury before proceeding to more
invasive means of cholangiography. CT angiography, with
dual arterial and portal venous phases, can be used to
define associated vascular injury. Magnetic resonance
cholangiopancreatography (MRCP) is an attractive
noninvasive imaging option if the diagnosis of a biliary
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injury is still in doubt. MR cholangiography can define an
interrupted or strictured bile duct, and contrast agents (e.g.,
Eovist) with biliary excretion can be used to document
biliary leaks on delayed images.
ERC is the best i nitial invasive study in a patient with a
suspected or confirmed biliary injury following
cholecystectomy. In injuries in whi ch the continuity of the
extrahepatic biliary tree is preserved, ERC may be both
diagnostic and therapeutic. Endoscopic sphincterotomy
and placement of an endobiliary stent is often sufficient to
treat biliary leaks from the cystic duct stump or small
accessory ducts. Incomplete transections may be bridged
by endobiliary stents, with the need for subsequent
operative intervention determined over time. In cases of
common bile duct ligation, or in instances where a segment
of the extrahepatic duct is excised with the gallbladder
leaving an open proximal and distal extrahepatic bile duct,
ERC may not be adequate to provide anatomic detail of
the proximal biliary tree, nor able to facilitate crossing the
injury. In these cases, PTC with placement of transhepatic
biliary drains is typically necessary, and PTC should be
performed in all patients with suspected bile duct injury in
whom ERC was either not technically feasible or not
definitive.
PTC in a patient with a recent ductal ligation or leak,
and thus a decompressed biliary system, is difficult and
often requires sophisticated interventional radiology
resources and expertise. It is often necessary to place
additional percutaneous drains to control bile leakage and
drain infected bilomas until the biliary drainage is
adequately diverted. These patients truly require
multidisciplinary management to ensure that procedures
are coordinated with the goals of improving the patient’s
condition, defining the relevant anatomy, and facilitating
eventual definitive repair. For this reason, the hepatobiliary
surgeon needs to be involved in all decisions about
placement of drains and transhepatic catheters, and the
timing of these procedures.
Direct cholangiography allows classification of the type
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of biliary injury (F ig ur e 1) according to the BismuthStrasberg classification. Type A i njuries occur due to
leakage from the cystic duct stump or accessory ducts
draining directly into the gallbladder (ducts of Luschka) and
present as a biliary leak and/or subhepatic biloma. Type B
injuries are defined as ligation and division of an
anomalous segmental hepatic duct, typically the duct
draining segment 6 (± segment 7). This injury is often
facilitated by the associated anomaly where the cystic duct
drains into the right posterior duct. The proximal and distal
ends of the anomalous segmental duct are clipped and
divided during control of the cystic duct. Type B injuries are
often asymptomatic or may present late with abdominal
pain or cholangitis involving the occluded liver segment.
Normally, the liver behind a type B injury will atrophy over
time, often indolently. Type C injuries occur in the same
anatomic setting as type B injuries, though the proximal
ductal segment is not ligated and leaks freely into the
peritoneal cavity. The difficulty in type C injuries lies in their
diagnosis, as ERC typically misses the leaking segment as
it is not opacified via the main biliary tree. Cholangiograms
should be carefully inspected to make sure all liver
segments are visualized; when the posterior segment is not
seen, PTC may be diagnostic and allow control of the leak.
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FIGURE 1 • The Bismuth-Strasberg classification of biliary injuries following
laparoscopic cholecystectomy. (Reproduced from Winslow ER, Fialkowski
EA, Linehan DC, et al. “Sideways”: results of repair of biliary injuries using
a policy of side-to-side hepaticojejunostomy. Ann Surg. 2009;249(3):426–
434, with permission.)
In type D injuries, a lateral injury to the extrahepatic bile
duct occurs, either sharply or by thermal injury. The biliary
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tree remains in continuity, and the injury may manifest with
a leak initially or a stricture in a delayed presentation.
These injuries may be diagnosed accurately by ERC, which
can also provide definitive treatment via endobiliary
stenting.
Type E injuries are defined by complete disruption of
biliary–enteric continuity due to transection, excision,
and/or ligation of the extrahepatic biliary tree. Injuries that
include a free biliary leak will prevent early with bile
peritonitis and sepsis. Injuries with occlusion of the
proximal hepatic drainage may present in a delayed
fashion with jaundice and/or cholangitis, although still
typically within 2 weeks of cholecystectomy as all biliary
drainage is occluded. Type E injuries are further described
according to the Bismuth classification (E1 to E5, as
depicted in Figure 1), with important implications about the
complexity of definitive repair. The majority of type E
injuries will require PTC to definitively reveal the anatomic
details of the injury and to establish stable biliary drainage.
In the present case, CT demonstrates the patient to
have a large right upper-quadrant fluid collection. The
collection is percutaneously drained, revealing frank bilious
output that grows gram-negative organisms in culture.
Antibiotics are initiated. ERC reveals an obstructed bile
duct at the level of the cystic duct. PTC is performed
demonstrating a complete transection of the hepatic duct
within 2 to 3 mm of the bifurcation (type E3 injury, Figure 2,
panel A). A transhepatic biliary drain is left in place,
providing external biliary drainage (Figure 2, panel B,C).
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FIGURE 2 • Type E3 biliary injury managed with U tube percutaneous biliary
drainage and delayed Roux-en-Y hepatico-jejunostomy. PTC on
postoperative day 5 following laparoscopic cholecystectomy reveals type
E3 injury with biliary leak (panel A). A wire was able to be passed from
percutaneous access to the right hepatic across the hepatic duct
bifurcation and retrieved from percutaneous access to the left hepatic duct,
allowing placement of a U tube for external biliary drainage (panel B). The
patient recovered over the ensuing 12 weeks, during which time the biliary
leak resolved with stable U tube drainage (panel C). At the time of hepati-
cojejunostomy, the U tube was exchanged for individual bilateral biliary
catheters placed across the anastomosis. The catheters were removed 3
weeks after repair when cholangiogram revealed a well-healed patent
hepati-cojejunostomy (panel D).
Diagnosis and Treatment
The management of bile duct injuries should be catered to
the condition of the patient, timing of the injury, and
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anatomic details according to the Bismuth-Strasberg
classification. Principles that apply in all cases include
control of sepsis, drainage of all bile collections, and
establishment of secure biliary drainage. Ongoing
reassessment of the patient’s clinical condition, with
reimaging as clinically indicated to detect undrained
bilomas, will get even the frailest patients through what can
be tenuous early stages of their injury, allowing definitive
repair to be performed in an elective fashion on a healthy
patient. Timing of definitive repair for those patients that
require biliary reconstruction is an individualized decision
that requires careful surgical judgment.
Specific treatment strategies for bile duct injuries can
be determined according the Bismuth-Strasberg
classification, as summarized in Table 1. The decision
making about the urgency of intervention and the need for
surgical reconstruction varies based upon the timing of the
patient’s presentation, and the patient’s clinical condition.
Injuries recognized at the time of cholecystectomy, or within
the immediate postoperative period (48 to 72 hours), can
be considered for early repair.
TABLE 1. The Bismuth-Strasberg Classification of Biliary Injuries
Following Laparoscopic Cholecystectomy
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In the case of injuries recognized intraoperatively at the
time of cholecystectomy, immediate repair should only be
performed when adequate surgical experience and
expertise are available and the extent of the injury is
completely understood. The inability to perform good
quality cholangiography, or the lack of surgical experience
with biliary–enteric anastomoses, are examples of
contraindications to immediate repair. Other relative
contraindications to early repair include an associated
vascular injury, hemodynamic instability, excessive blood
loss, or a thermal injury to the duct with extensive
devitalized tissue.
In the case of patients who present in the first 48 to 72
hours after cholecystectomy, early repair may be
considered if the patient is clinically well without signs of
sepsis or hepatic dysfunction, and the anatomic details of
the injury are well understood with cholangiography.
Relative contraindications to early repair include
associated vascular injury, thermal injury with extensive
devitalized tissue, and Class E3 or greater injuries where
achieving a quality repair to healthy tissue can be difficult in
the acute setting.
In patients presenting beyond 72 hours from
cholecystectomy, and/or with signs of intra-abdominal
sepsis, the initial priorities should be appropriate
resuscitation, broad-spectrum antibiotics, cross-sectional
imaging, and percutaneous drainage of all significant fluid
collections. Direct cholangiography via ERC or PTC is the
next step, with an attempt to obtain definitive internal or
external biliary drainage. Once biliary drainage is
established, the pressure of time is removed and the
patient should be allowed to recover from the
cholecystectomy and any associated sepsis. Most
hepatobiliary surgeons will wait 6 to 8 weeks or more
before proceeding with biliary reconstruction. This delay
allows for the resolution of any associated peritonitis,
provides time for collateralized biliary blood flow to be
established, and allows the patient to rehabilitate
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Surgical Approach
The preferred method for repairing most injuries is a Rouxen-Y hepaticojejunostomy (Table 2), and the key principles
include creation of a tension-free anastomosis to healthy
hepatic ducts that drain all biliary segments. Direct end-toend repair of the extrahepatic bile duct is often
unsatisfactory when a significant section of the duct has
been devitalized or removed, and is associated with a high
rate of additional complications especially stricture.
TABLE 2. Key Technical Steps and Potential Pitfalls in Roux-en-Y
Hepatico-jejunostomy Procedure
Care should be taken to choose a part of the proximal
jejunum that reaches easily to the right upper quadrant. The
small bowel should be divided at an appropriate place with
a GIA stapler, and the mesentery divided to allow the Roux
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