The laparoscopic approach has replaced open surgery as the gold standard for cholecystectomy. This technique is, however, associated with a greater incidence of bile duct injuries (BDIs). We report a case of portobiliary fistula (PBF), a rare complication of BDI, occurring post laparoscopic cholecystectomy (LC). PBF has been reported after procedures such as endoscopic retrograde cholangiopancreatography and pathologies such as liver abscesses, but only once previously in the setting of LC. We discuss the management of this patient with apparent dual pathology, and summarise other aetiologies that may give rise to this condition.
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Laparoscopic cholecystectomy -Bile ducts -FistulaAccepted 31 January 2016Laparoscopic cholecystectomy (LC) has replaced open surgery as the gold standard for cholecystectomy due to reduced postoperative pain and length of hospital stay, and a faster return to activities of daily living. Despite a reduction in both surgical and systemic-related complications, there remains a significant risk of bile duct injuries (BDIs) with the laparoscopic technique. Although this was initially attributed to a 'learning curve' effect, it has persisted for two decades.1 We report on a rare complication of BDI following LC.
Case ReportA 48-year-old female of Chinese origin presented 3 days after an intially uncomplicated laparoscopic cholecystectomy with abdominal pain radiating to her shoulder tip. Blood tests on admission showed raised inflammatory markers (white cell count 14.8x10 9 /L, C-reactive protein 183 mg/L) and deranged liver function tests (alanine transaminase 132 IU/L, alkaline phosphatase 148 IU/L). A suspected bile leak was investigated with a computed tomography (CT) scan. This revealed subphrenic free fluid with air locules, free intraperitoneal air and focal intrahepatic biliary dilatation in the left lobe of liver.Endoscopic retrograde cholangiopancreatography (ERCP) was attempted, but the patient did not tolerate the procedure. An emergency exploratory laparotomy was undertaken, which revealed a Bismuth Grade IV injury to the distal right hepatic duct. After thorough peritoneal lavage, a T-tube was inserted across the identified site of injury, with placement of a 20 FG Robinson's drain behind the portal triad. Following