Combined endoscopic and surgical management of a right intrahepatic bile duct injury during laparoscopic cholecystectomy

Biliary tract wounds are a rare complication of cholecystectomy [1]. They lead to the appearance of intra- or extrahepatic biliary stenosis, which usually requires endoscopic treatment [2] [3] [4]. They occur mainly when inflammation persists after cholecystitis or angiocholitis. The direct connection of the right posterior bile duct to the common hepatic duct is a well-known anatomical variant of the biliary tract, which can lead to the sectioning of the right posterior bile duct during cholecystectomy [1]. We report here the case of a 70-year-old woman who underwent laparoscopic cholecystectomy following acute cholecystitis. During the procedure, bile flow was found after sectioning of the cystic duct. Intraoperative opacification of the biliary tract showed it being in fact the right posterior bile duct. At the same time, an endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy was performed. After biliary wound catheterization, the guidewire was introduced inside the right posterior bile ducts laparoscopically ([Fig. 1]). A 7 Fr × 15 cm plastic biliary stent was then placed under endoscopic, fluoroscopic, and laparoscopic guidance inside the right posterior bile ducts to aid healing of the bile duct ([Video 1]).

Fig. 1 Cholangiography during laparoscopic cholecystectomy. a Right posterior intrahepatic bile ducts (arrow). b Right posterior bile duct catheterization with guidewire placement in the right intrahepatic bile duct (arrow). c Placement of a plastic biliary stent (arrow) in the right intrahepatic bile duct to serve as a guide for biliary wound healing.

Video 1 Endoscopic retrograde cholangiopancreatography during laparoscopic cholecystectomy with positioning of a biliary plastic stent with laparoscopic guidance for a right posterior bile duct injury.

Magnetic resonance imaging of the biliary tract was performed 2 months later ([Fig. 2]). It did not reveal any anomaly of the bile ducts and the stent was still in place. A new ERCP was performed to remove the stent. Retrograde cholangiography found no biliary leakage but instead satisfactory opacification of the entire biliary tree ([Fig. 3]).

Fig. 2 Biliary magnetic resonance imaging 2 months after the plastic stent was placed, showing healing of the right posterior hepatic duct (arrow).

Fig. 3 Endoscopic retrograde cholangiopancreatography performed 2 months after laparoscopic cholecystectomy with biliary stent ablation and cholangiography.

This case illustrates the effectiveness of immediate and joint management of biliary leakage during cholecystectomy. The immediate stent placement aided healing but also ensured patency of the injured bile duct and thus avoided the occurrence of biliary stenosis [5].

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• References

• 1 Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002; 9: 543-547
• 2 Chow S, Bosco JJ, Heiss FW. et al. Successful treatment of post-cholecystectomy bile leaks using nasobiliary tube drainage and sphincterotomy. Am J Gastroenterol 1997; 92: 1839-1843
• 3 Rainio M, Lindström O, Udd M. et al. Endoscopic therapy of biliary injury after cholecystectomy. Dig Dis Sci 2018; 63: 474-480
• 4 Schmitt CM, Baillie J, Cotton PB. ERCP following laparoscopic cholecystectomy: a safe and effective way to manage CBD stones and complications. HPB Surg 1995; 8: 187-192
• 5 Pesce A, Palmucci S, La Greca G. et al. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol 2019; 12: 121-128