Managing complex bile duct injury after laparoscopic cholecystectomy

52 year old gentleman presented to us with an indwelling drainage catheter draining bile after a laparoscopic cholecystectomy.

He had undergone laparoscopic cholecystectomy at a private hospital for acute calculus cholecystitis / empyema of gall bladder. 2 days after the surgery, bile was noticed in drain that was placed during surgery. MRCP & ERCP showed bile duct injury for which an endoscopic stenting of bile duct was attempted, however stent could not reach the injured portion of bile duct it being high complex biliary injury. At this point patient was discharged with drain (bile fistula) and medications from previous hospital.

Patient presented to us almost 3 weeks after 1st surgery with 400-500 ml bile output. A fresh MRCP followed by a PTBD was done to divert the bile externally and allow healing inside. Also antibiotics were adjusted as per the bile culture. Patient was started on enteral and partial parenteral nutrition. However due to nature of injury, small quantity of bile continued to leak. Bile output kept fluctuating in spite of all efforts to adjust the PTBD catheters.

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👆 Hole in the bile duct wall with externally draining catheters (2 white and 1 green)

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Over the next few weeks patient had few more problems like left portal vein thrombosis and pseudoaneurism of left hepatic artery branch inside the liver. The pseudoaneurism was managed by angioembolisation. Finally patient was taken up for surgery at the end of ten weeks from 1st surgery. The site of injury was identified and a wide anastomosis. was performed with a loop of small intestine.

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👆 Intestine joined to the defect in bile duct wall.

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The patient recovered well over next few weeks after which the drains and PTBD catheters were gradually removed. It’s been 5 months since the initial surgery now and patient is well at home.

Bile duct injury during laparoscopic cholecystectomy is one of the most worrisome complications of the procedure. ( Fortunately it is very rare in experienced hands) Hence laparoscopic cholecystectomy should not be taken lightly especially when it is being done for difficult problems. It should be done by experienced surgeon and avoiding an injury is of paramount importance. Bile duct injury can manifest early after surgery in the form of bile leak or bile duct obstruction or late in the form of bile duct strictures. Simple injuries can usually be managed with stents. Some of these patients can develop late bile duct narrowing. Complex bile duct injury are high (hepatic duct / ducts) and can have associated vascular injuries. These are very difficult to handle and are best treated at center with appropriate experience in multidisciplinary management as we have shown.

Treatment of complex bile duct injury is a multidisciplinary management involving experienced hepatobiliary surgeon, gastroenterologist with advanced endoscopy experience and an interventional radiologist. The aim is to stop or control the leak, control infection, maintain nutrition and achieve biliary enteric connectivity using stents, external drainage tubes or surgery. Sometimes additional procedures like arterial embolisation and extensive surgery like partial hepatectomy are required. Improper treatment can lead to loss of life due to infections, bleeding or chronic irreversible liver damage (secondary biliary cirrhosis).