Posterior hepatic duct injury during laparoscopic cholecystectomy finally necessitating hepatic resection: case report

Abstract

A case of bile duct injury during laparoscopic cholecystectomy finally necessitating right hepatic lobectomy is reported to re-emphasize the importance of preoperative and intraoperative assessment of the biliary tree. A 47-year-old Japanese woman underwent laparoscopic cholecystectomy for cholecystolithiasis. On postoperative day 5, fever and right hypochondralgia developed, and CT revealed fluid collection at the right hypochondrium. Percutaneous drainage was performed, and subsequent fistulography revealed a communication of the cystic cavity with the right posterior bile duct, which suggested injury of the aberrant hepatic duct. Conservative therapy, including the adaptation of fibrin glue, was performed, but closure of the fistula and cavity was not obtainable. Finally, a right hepatic lobectomy was performed four months after cholecystectomy. In this case, endoscopic retrograde cholangiopancreatography was unsuccessful preoperatively, and intraoperative cholangiography was not done. This case report re-emphasizes that the preoperative and intraoperative examination of the biliary tree is mandatory to avoid bile duct injury.

Figure 1a.

Drip infusion cholangiography demonstrating the normal common hepatic duct but not representing the gallbladder. Figure 1b. Fistulogram demonstrating the posterior segmentai bile duct having no connection to the common bile duct. Figure 1c. Intraoperative cholangiography demonstrating a confluence of the right anterior hepatic duct and left hepatic duct without posterior segmental branch. The injured posterior hepatic duct was close to the clips. Figure 1d. Postoperative cholangiography after right hepatic lobectomy.

Figure 2a.

Computed tomography after laparoscopic cholecystectomy demonstrating an abnormal fluid collection in the right upper quadrant region. Figure 2b. Computed tomography before hepatic resection demonstrating a subcapsular hematoma of the right hepatic lobe and an abscess in the subsegment.

Figure 3.

A schema of the biliary system during hepatic resection in our case. F: Fistula by percutaneous abscess drainage; C: Cavity; H: Hematoma; AHD: Anterior hepatic duct; PHD: Posterior hepatic duct; LHD: Left hepatic duct; RPV: Right portal vein; PV: Portal vein; CBD: Common bile duct; CD: Cystic duct, which ran in parallel with CBD and entered in lower part of CBD.