Laparoscopic Cholecystectomy: Complications and Management

Initial management of suspected biliary injury after laparoscopic cholecystectomy

“…When a complete transection of CBD is not present, trans-papillary downstream control of the leak by ERC allows healing in more than 90% of biliary leaks[ 9 , 10 , 34 ]. In ERC occult CBD stones obstructing the bile flow and predisposing to leak can also be easily removed.…”

“…However, when a stent has been inserted, biliary sludge, stones, or occasionally even a persistent leak may be found at the time of stent removal. Thus, a stent may be preferable to sphincterotomy alone, which can be considered a mere secondary alternative when stone clearance is confirmed and second endoscopy for stent removal would be too risky[ 9 , 34 ]. However, a recent randomised controlled trial proved that after appropriate patient selection in a simple Strasberg type A leak, endoscopic sphincterotomy may be a safe and cost-effective single procedure without stent insertion[ 12 ].…”

“…In this scenario, comparing ERC cholangiography to pre-operative MRI may be the way to diagnose this type of lesion correctly[ 29 ]. A fistulography performed via the catheter drain may also help in determining the extent of the lesion[ 9 ]. When the bile duct is disconnected or the main branches entirely transected, early surgery or a combination of external drainage of biloma and percutaneous transhepatic cholangiogram catheter (PTC) for proximal control may be necessary in the early phase in order to gain time for definitive treatment[ 8 ].…”

“…According to the literature, the optimal timing of definite reconstructive re-operation varies[ 9 , 15 ]. However, when a complex BDI unamenable to treatment by ERC is diagnosed after the operation, early surgical repair is generally not recommended, especially when diagnosis is delayed or sepsis, biliary peritonitis or arterial injury are concomitant[ 8 , 9 ]. In these cases, the definitive reconstruction should preferably be delayed for up to a few months and preceded by e.g.…”

“…As most cholecystectomies are operated on laparoscopically, BDI occurs in 0.2%-0.9% of patients; the variation depends on whether all bile leaks or only surgically reconstructed injuries are included[ 4 - 6 ]. Commonly graded by Strasberg´s classification[ 7 ], bile duct injuries are graded from A to E, where A represents a simple cystic duct leak and C-E complex injuries to the hepatic ducts or common bile duct (CBD)[ 7 - 9 ] (Figure 1 ). Most post-cholecystectomy bile leaks are mild type A-B lesions, where endoscopic treatment combined with external drainage is usually successful[ 10 - 12 ].…”