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30 Case on CBD Lesion During Laparoscopic Cholecystectomy
https://t.me/med1917
Lesion of CBD
Hepaticojejunostomy
+ venous bypass
right hepatic artery
Illustration 30.1 After diagnosing a complete transection of the CBD by laparoscopic cholecystectomy, it was recommended to leave a catheter in the proximal part of the divided bile duct and
to transfer the patient to a specialized center. At operation, fi rst, a venous reconstruction of the right
hepatic artery was performed and, second, a bile duct reconstruction was done by means of a
Roux-en-Y hepaticojejunostomy
165
Reference
1. Booij KAC, Gouma DJ, van Gulik TM, Busch ORC. Prevention and treatment of major com-
plications after cholecystectomy. In Cuesta MA and HJ Bonjer, editors. Treatment of complica-
tions after Digestive Surgery. Chapter 12 a. Springer, London 2013.
Chapter 31
https://t.me/med1917
Case on CBD Lesion During Laparoscopic
Cholecystectomy
Oliver R.C. Busch , Klaske A.C. Booij , Dirk J. Gouma ,
and Thomas M. van Gulik
Keywords CBD lesion • Laparoscopic cholecystectomy • Cholecystolithiasis •
Hepaticojejunostomy • Balloon angioplasty
Diagnosis, Indication for Surgery and Operation
A 30-year-old female patient had complaints of cholecystolithiasis and therefore
a laparoscopic cholecystectomy was performed.
Postoperative Course: Identifi cation and Treatment
of Complication
Because of jaundice a week after operation, an ERCP was performed which
demonstrated a complete transection of the CBD. Therefore, a hepaticojejunostomy
was created which was complicated by fever, acute respiratory distress syndrome,
and sepsis requiring intensive care treatment. Because of persistent fever and jaundice, patient was referred to our clinic. Computer tomography (CT) of the abdomen
showed dilated intrahepatic bile ducts of the posterior segments, suggesting that a
segmental bile duct was not connected to the hepaticojejunostomy (Fig. 31.1 ).
Drainage of the right hepatic ducts was established by a percutaneous transhepatic
O. R.C. Busch , M.D., Ph.D. (*) • K. A.C. Booij • D. J. Gouma • T. M. van Gulik
Department of Surgery , Academic Medical Center ,
Amsterdam , The Netherlands
e-mail: o.r.busch@amc.uva.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_31,
© Springer International Publishing Switzerland 2014
167
168
https://t.me/med1917
Fig. 31.1 Computer
tomography of the abdomen
revealed dilated bile ducts of
the posterior segments of the
right liver
Fig. 31.2 PTC demonstrated
leakage of the segmental bile
ducts which were not
included in the
hepaticojejunostomy
O.R.C. Busch et al.
cholangiography (PTC) catheter (Fig. 31.2 ). Further analysis by magnetic resonance
cholangiopancreatiocography (MRCP) revealed that the bile ducts of segments VI
and VII were not drained by the hepaticojejunostomy. Six months after initial operation, a new hepaticojejunostomy was constructed (Illustration 31.1 ). The
31 Case on CBD Lesion During Laparoscopic Cholecystectomy
https://t.me/med1917
Illustration 31.1 A
hepaticojejunostomy was
performed because of
transection of the CBD during
laparoscopic
cholecystectomy. Because of
persistent fever and jaundice a
CT scan of the abdomen
showed dilated intrahepatic
bile ducts of the posterior
segments, suggesting that a
segmental bile duct was not
connected to the
hepaticojejunostomy. After
drainage by PTC, further
analysis by MRCP revealed
that the bile ducts of segments
VI and VII were not drained
by the hepaticojejunostomy.
Six months after initial
operation, a new hepaticojejunostomy was performed
169
Segments VI and VII
not connected with
anastomosis
postoperative course was uneventful. Currently, 8 years after hepaticojejunostomy,
patient was treated twice because of stenotic complaints of the anastomosis requiring PTC and balloon angioplasty.
Discussion
The most devastating complication after cholecystectomy is Bile Duct Injury (BDI),
with a reported incidence of 0–1.5 %. The key issue in the management of BDI is
prevention. Prevention is only adequate with the awareness of pre- and
170
https://t.me/med1917
O.R.C. Busch et al.
intraoperative risk factors, the use of CVS, experience in performing cholecystectomy and knowledge of the different escape strategies in the case of a diffi cult cholecystectomy. BDI can be diagnosed either peroperatively or in the direct or late
postoperative phase. In case BDI occurs, the severity of the injury should be classifi ed thoroughly before a proper treatment can be chosen. The treatment of BDI
should be performed by a multidisciplinary team and only if suffi cient experience in
dealing with this complication is present. If not, the patients should be referred to a
tertiary center. Even after an objectively excellent outcome of treatment, the reported
QoL is still reduced [ 1 ].
Reference
1. Booij KAC, Gouma DJ, van Gulik TM, Busch ORC. Prevention and treatment of major com-
plications after cholecystectomy. In Cuesta MA and HJ Bonjer, editors. Treatment of complica-
tions after Digestive Surgery. Chapter 12 a. Springer, London 2013.
Chapter 32
https://t.me/med1917
Case on Hepatic Abscess After Double
Lesion (CBD and Right Hepatic Artery)
During Cholecystectomy
Miguel A. Cuesta
Keywords Hepatic abscess • Double lesion • Right hepatic artery • Cholecystectomy
• Conversion • Cholelithiasis
Identifi cation and Treatment of Complication
A 56-year-old female patient was transferred to our unit because of biliary leakage
after a converted laparoscopic cholecystectomy had been performed in another hospital. It was her fi fth postoperative day; patient had a productive drain of more than
700 cc bile per day, she was treated with broad spectrum antibiotics, and had a
gastric tube for enteral feeding. She was not jaundiced, had fever, and a deep wound
infection had already been drained. A complete blood examination, a CT scan of the
thorax and abdomen, and ERCP were performed (Fig. 32.1 ). A proximal and com-
plete lesion of the hepatic duct was seen (type D BDI) with an insuffi ciently drained
subhepatic collection. Along with this, a decrease of arterial circulation of the
hepatic right segments was also observed. A PTC drain was placed to properly drain
the collection.
Patient was treated conservatively during 2 weeks in order to improve her general condition and to treat the wound sepsis. After a postoperative period of 6 weeks
she was reoperated.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_32,
© Springer International Publishing Switzerland 2014
171
172
https://t.me/med1917
Fig. 32.1 ERCP showing the
complete CBD lesion
Operation
M.A. Cuesta
A bilio-digestive anastomosis by means of a Roux-en-Y loop was performed
(Illustration 32.1 ).
Postoperative Course
Postoperatively, she had a small biliary leakage through the drain, being treated
conservatively. Splints and percutaneous drain were removed 6 weeks after operation once cholangiography showed that the anastomosis was patent and had no
leaks. She did postoperatively quite well, but a signifi cant depression required her
to follow psychological support.
Eighteen months later she was acutely admitted to the Intensive Care Unit
because of septic shock caused by a right hepatic abscess. On the CT scan it became
clear that the right segments of the liver were atrophic and progressively replaced
by a big abscess (Fig. 32.2 ). Patient was mechanically ventilated with high PEEP,
the liver abscess drained twice percutaneously (Illustration 32.1 ), and she received
iv broad spectrum antibiotics (Fig. 32.3 ). Slowly she could be retired from mechani-
cal ventilation and after a recovery period of 5 weeks she could be admitted to a
revalidation center. Since then, she is controlled at an outpatient polyclinic.
Remarkably, she has only general complaints and an adequate liver function. On CT
scan a hypertrophic left lobe and atrophic right segments without signs of portal
32 Case on Hepatic Abscess After Double Lesion
https://t.me/med1917
Illustration 32.1 During conversion to open cholecystectomy an unrecognized lesion was performed of the CBD. It was identifi ed as a type D BDI. A hepaticojejunostomy was performed.
One-half year later she was admitted because of liver abscesses in the relative atrophic right lobe
of the liver with hypertrophic left lobe, and signs of a lesion of the right hepatic artery.
Conservatively treated by drainage she recovered. In case of recurrence, a right hepatectomy
should be done
173
Fig. 32.2 CT scan. Atrophic
right liver lobe with
abscesses
174
https://t.me/med1917
Fig. 32.3 CT scan guided
percutaneously drainage of
the abscesses
M.A. Cuesta
hypertension or dilated biliary system are seen. In the event the abscess recurs, a
resection of the atrophic right lobe will need to be considered.
Discussion
The most devastating complication after cholecystectomy is Bile Duct Injury (BDI),
with a reported incidence of 0–1.5 %. The key issue in the management of BDI is
prevention. Prevention is only adequate with the awareness of pre- and intraoperative risk factors, the use of CVS, experience in performing cholecystectomy and
knowledge of the different escape strategies in the case of a diffi cult cholecystectomy. BDI can be diagnosed either peroperatively or in the direct or late postoperative phase. In case BDI occurs, the severity of the injury should be classifi ed
thoroughly before a proper treatment can be chosen. The treatment of BDI should
be performed by a multidisciplinary team and only if suffi cient experience in dealing with this complication is present. If not, the patients should be referred to a
tertiary center. Even after an objectively excellent outcome of treatment, the reported
QoL is still reduced [
1 ] .
Reference
1. Booij KAC, Gouma DJ, van Gulik TM, Busch ORC. Prevention and treatment of major com-
plications after cholecystectomy. In Cuesta MA and HJ Bonjer, editors. Treatment of complica-
tions after Digestive Surgery. Chapter 12 a. Springer, London 2013.
Chapter 33
https://t.me/med1917
Case on Unrecognized CBD Stones
After Laparoscopic Cholecystectomy
Akash M. Metha
Keywords CBD stones • Laparoscopic cholecystectomy • Anorexia • Biliary
leakage • Acute cholecystitis
First Patient
Diagnosis and Indication for Surgery
A 35-year-old female patient, with no previous history, was presented to the
Emergency Department because of progressive upper-right abdominal pain since 5
days. Patient experienced nausea and anorexia. On physical examination, the upperright quadrant of the abdomen was tender, though there were no local signs of peritonitis. A leukocytosis of 8.9 × 10 9 /L and a C-reactive protein of 132 mg/L were
found. Hepatic tests were all within the normal range. Abdominal ultrasonography
showed an acute cholecystitis with gallstones. Intrahepatic bile ducts were mildly
dilated, without dilatation of the common bile duct (CBD). Patient was admitted
and it was decided to perform a laparoscopic cholecystectomy.
Operation Description
During laparoscopy, a severely infl amed gallbladder was visualized; and due to
severe edema of the wall, the critical view of safety of the Hilar structures could
A.M. Metha , M.D.
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: a.metha@nki.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_33,
© Springer International Publishing Switzerland 2014
175
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