Complete section of the common bile duct during complicated cholecystectomy: laparoscopy-guided endoscopic treatment, a mini-invasive approach

Although widely practiced, cholecystectomy can expose patients to serious biliary injuries, including biliary leakage, stenosis, and more rarely section of the common bile duct (CBD) [1] [2].

We report here the case of a 29-year-old woman who had previously undergone sleeve gastrectomy. She presented with acute cholecystitis ([Fig. 1]) and underwent a laparoscopic cholecystectomy. In the days following surgery, significant cholestasis became apparent, although without obvious symptoms. A computed tomography (CT) scan and magnetic resonance cholangiography did not reveal any major biliary lesions, but a collection was observed in the cholecystectomy site, with minor hepatic perfusion disorder.

Fig. 1 Abdominopelvic computed tomography scan before cholecystectomy showing: a on coronal section, minimal intrahepatic bile duct dilatation (green arrow); b on coronal section, cholecystitis with macrocalculi in the cystic duct (red arrow); c on axial section, cholecystitis with macrocalculi in the cystic duct (red arrow).

Subsequently, 10 days after the surgery, the patient’s condition remained unfavorable, with significant abdominal pain. A further CT scan was performed, which showed a large abdominal effusion, with fat infiltration in the cholecystectomy space ([Fig. 2]). An emergency laparoscopy was performed, which revealed biliary peritonitis ([Fig. 3]), so an endoscopic retrograde cholangiopancreatography (ERCP) was performed at the same time to treat the biliary leak ([Video 1]).

Fig. 2 Abdominopelvic computed tomography scan 10 days after surgery showing on axial sections the cholecystectomy clips, with fat infiltration in the cholecystectomy site, but no bile duct dilatation.

Fig. 3 Laparoscopic image showing biliary peritonitis.

Endoscopic and laparoscopic repair of the common bile duct after it had been completely sectioned during laparoscopic cholecystectomy.Video 1

The laparoscopy revealed surgical clips closing the extrapancreatic CBD, which had been completely sectioned. All of the clips were removed, revealing two intrahepatic ducts, which were reached by ERCP under laparoscopic guidance. Biliary opacification revealed normal intrahepatic ducts ([Fig. 4]), and two guidewires were positioned in the intrahepatic ducts and held in place surgically, which then allowed these ducts to be drained by placing 15- and 12-cm 7-Fr plastic stents ([Fig. 5]). The left intrahepatic ducts could not be efficiently drained, but the cholangiogram showed that parts of these were draining into the right side of the liver. Additional percutaneous biliary drainage of the left side of the liver was performed to finalize the connection between the CBD and intrahepatic ducts and therefore facilitate the formation of a neo-CBD.

Fig. 4 Fluoroscopic images showing bile duct opacification after laparoscopic- and endoscopic-guided selective cannulation.

Fig. 5 Laparoscopic and endoscopic view of the two plastic stents placed endoscopically to create a new common bile duct.

A few years ago, we illustrated the endoscopic treatment of a sectioned right posterior bile duct during laparoscopic cholecystectomy [3]. Here, we demonstrate the possibility of performing endoscopic treatment for a completely sectioned CBD under laparoscopic guidance, even at a distance from the biliary wound.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Flum DR, Cheadle A, Prela C. et al. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 2003; 290: 2168-2173
• 2 Emara MH, Ali RF, Mahmoud R. et al. Postcholecystectomy biliary injuries: frequency, and role of early versus late endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2021; 33: 662-669
• 3 Mayer P, Héroin L, Habersetzer F. et al. Combined endoscopic and surgical management of a right intrahepatic bile duct injury during laparoscopic cholecystectomy. Endoscopy 2022; 54: E682-E683

Publication History

Article published online:
18 November 2024