Prevention of Bile Peritonitis by Laparoscopic Evacuation and Lavage after Nonoperative Treatment of Liver Injuries

Abstract

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Laparoscopic Cholecystectomy for Management of Uncomplicated Gall Bladder Mucocele in Six Dogs

“…Perhaps future research will demonstrate the adequacy of laparoscopic intra‐abdominal lavage and drainage in dogs where perforation has occurred. A laparoscopic approach described for management of bile peritonitis after blunt liver trauma in humans has had very good results 12,13 . Dogs with biliary tract obstruction may also become candidates for LC if minimally invasive common bile duct access can be performed to ensure biliary tract patency.…”

Liver trauma: WSES 2020 guidelines

“…Bile peritonitis has been usually treated with laparotomy. Combination of laparoscopic irrigation/drainage and endoscopic bile duct stent placement may represent a valid alternative [101,102,112,113].…”

Successful utilization of angioembolization and delayed laparoscopy in the management of grade 5 hepatic laceration: Case report and literature review

“…Surgeons at the University of Louisville were early advocates for delayed laparoscopy after angioembolization in blunt hepatic trauma [[11], [12], [13], [14]]. They outlined their operative technique in a case series with fifteen patients.…”