Management of biliary injury after laparoscopic cholecystectomy N. Dayes Kings County Hospital Center & Long Island College Hospital 8/19/2010

Size: px

Start display at page:

Download "Management of biliary injury after laparoscopic cholecystectomy N. Dayes Kings County Hospital Center & Long Island College Hospital 8/19/2010"

Ashlynn Reynolds
5 years ago
Views:

1 Management of biliary injury after laparoscopic cholecystectomy N. Dayes Kings County Hospital Center & Long Island College Hospital 8/19/2010

2 Case Presentation 30 y.o. woman with 2 weeks of RUQ abdominal pain 3 rd ED visit. No nausea or vomiting PMHX PCOS, obesity, previous admission in 2007 for acute cholecystitis PSHX none FAM / SOC HX non-contributory

3 Case Presentation Physical exam A febrile Vital signs are within normal limits Abd: RUQ tenderness Laboratory Data WBC 7.3, H/H -13/40, Plt- 260 LFT TP 6.8 /Alb 4.2 /AST-25 / ALT-41 /Alk Phos 61/TB 0.1 Chemistry, amylase, and lipase are within normal limits

4 Case Presentation RUQ ultrasound cholelithiasis with gallstone in gallbladder neck, no pericholecytic fluid, distended gallbladder, normal gallbladder wall

5 Case Presentation HOD#2 Pt. taken to OR for laparoscopic cholecystectomy Operative Detail The gallbladder fundus was retracted superiorly and the infundibulum retracted laterally Reduced mobility of gallbladder secondary to its socked-in nature The peritoneum was released along the medial and lateral portions of the infundibulum. Difficult dissection

6 Case Presentation Operative Detail (cont d) Cystic duct and artery were identified and ligated Gallbladder was released from hepatic bed with electrocautery 10mm flat Jackson Pratt drain

7 Case Presentation POD #1 Afebrile & vitals signs are within normal limits 400 ml of bilious fluid from JP drain LFTs are within normal limits Hepatobiliary imaging iminodiacetic acid (HIDA) scan ordered GI service consulted

8 Case Presentation - HIDA

9 Case Presentation POD # ml of bilious fluid from JP drain Endoscopic retrograde cholangiopanctreography performed

10 Case Presentation ERCP

11 Case Presentation POD # ml of bilious fluid from JP drain Interventional Radiology service consulted for percutaneous transhepatic cholangiogram

12 Case Presentation PTC

13 Case Presentation POD # 9 Hepatobiliary surgeon was consulted for Rouxen-Y hepaticojejunostomy Pt. was discharged home with external biliary drain and JP drain.

14 Case Presentation HOD #1/POD # 42 Admitted for exploratory laparotomy and Rouxen-Y hepaticojejunostomy and intraoperative cholangiogram

15 Case Presentation HOD #1/POD # 42 Operative Detail Right subcostal incision Strasberg type E2/ Bismuth type 2 injury Several clips around the common hepatic duct Single layer common hepatic duct to antecolic Roux limb anastomosis over an 8Fr feeding tube using interrupted 4-0 PDS sutures Intraoperative cholaingogram performed

16 Case Presentation Intraoperative cholangiogram

17 Case Presentation POD # 2 Passing flatus and started on clear liquid diet POD# 3 Tolerating regular diet POD#4 Post-op cholangiogram performed

18 Case Presentation Post-op cholangiogram

19 Case Presentation POD #8 Discharged home with clamped external biliary drain.

20 Case Discussion Mechanisms of bile duct injury Critical View of Safety Classification of biliary injuries Long term results of surgical reconstruction

21 Introduction Incidence of bile duct injury has risen from 0.2% to 0.6% Substantial effect on the quality of life of patients suffering biliary injury Excess of $50,000 per event

22 Classic mechanism of injury Misidentification of the biliary anatomy

23 Critical View of Safety In 1995, Soper and Strasberg introduced the concept of the critical view of safety Essential to clear the triangle of Calot Must separate the lowest part of gallbladder from the cystic plate Finally, only 2 structures should be seen entering gallbladder cystic duct and artery

24 Critical View of Safety

25 Critical View of Safety

26 Am Surg 2008;74: Retrospective review of all laparoscopic cholecystectomies done over a 5 year period in a single institution Critical View technique was used in all procedures Out of 3,042 cases analyzed, only 1 bile duct injury occurred Less than the expected 2 to 4 injuries per 1000 patients

27 Classification of biliary injury Strasberg type A Leak from cystic duct stump or minor liver bed ducts Tx : ERCP with stenting and percutaneous drainage of localized bile collections

28 Classification of biliary injury Strasberg type B An aberrant right hepatic duct is mistaken for the cystic duct and ligated Tx : non-operative management versus Rouxen-Y hepaticojejunostomy

29 Classification of biliary injury Strasberg type C Sectoral duct injury without occlusion Tx : Percutaneous drainage vs. Roux-en-Y hepaticojejunostomy

30 Classification of biliary injury Strasberg type D Partial injury to any extrahepatic duct Tx : Primary repair vs. Roux-en-Y hepaticojejunostomy

31 Classification of biliary injury Strasberg type E 1-5 / Bismuth 1-5 Excision or complete occlusion of the common hepatic or bile duct Tx : Roux-en-Y hepaticojejunostomy

32 Ann Surg 2005; 241:786. Single tertiary care institution s retrospective analysis of 200 patients with major duct injuries Largest experience reported by a single institution Rate of perioperative complications was 43% The timing of operation (defined as early, intermediate and delayed) did not change the incidence of the most common perioperative complications

34 Conclusion Timing of operation had no influence on perioperative complications. Median of 5.4 weeks after initial injury Most of these complications, although troublesome, can be managed conservatively Early referral to a tertiary care center to assure optimal short-term and long-term outcomes.

35 References Cohen J, Sharp K: Complications of laparoscopic cholecystectomy. Laparoscopic surgery of the abdomen, New York: Springer-Verlag; Deziel DJ: Complication of cholecystectomy: incidence, clinical manifestations, and diagnosis. Surg Clin North Am 1994; 74:809. Kaffes AJ, Hourigan L, De Luca N: Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy leak. Gastrointest Endosc 2005; 61:269.and others Lee CM, Stewart L, Way LW: Postcholecystectomy abdominal bile collections. Arch Surg 2000; 135:538. Lee VS, Chari RS, Cucchiaro G: Complications of laparoscopic cholecystectomy. Am J Surg 1993; 165:527.and others Murr M, Gigot JF, Nagorney DM: Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg 1999; 134:604.and others Sicklick J, Camp M, Lillemoe K: Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 2005; 241:786.and others Tumer AR, Yuksek YN, Yasti AC: Dropped gallstones during laparoscopic cholecystectomy: the consequences. World J Surg 2005; 29:437.and others Varshney S, Buttirini G, Gupta R: Incidental carcinoma of the gallbladder. Eur J Surg Oncol 2002; 28:4.

Background. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial

Background. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial RUQ Ultrasound Normal, Recommend Clinical Correlation Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial Background Incidence of pediatric gallbladder disease continues to rise U.S. Pediatric