Treatment of late identified iatrogenic injuries of the right and left hepatic duct after laparoscopic cholecystectomy without transhepatic stent and Witzel drainage: Case report

Abstract

Introduction: Most of the case reports about high type iatrogenic hepatic duct injuries reports how to treat and make Roux-en-Y hepaticojejunostomy below the junction of the liver immediately after this condition is recognised during surgical procedure when the injury was made. Hereby we present a case where we made Roux-en-Y hepaticojejunostomy without transhepatic billiary stent and also without Witzel drainage one month after the iatrogenic injury.

Presentation of case: A 21-year-old woman suffered from iatrogenic high transectional lesion of both hepatic ducts during laparoscopic cholecystectomy in a local hospital. Iatrogenic injury was not immediately recognized. Ten days later due to patient complaints and large amount of bile in abdominal drain sac, second surgery was performed to evacuate biloma. Symptoms reappeared again, together with bile in abdominal sac, and then patient was sent to our Clinical Center. After performing additional diagnostics, high type (Class E) of iatrogenic hepatic duct injury was diagnosed. A revision surgical procedure was performed. During the exploration we found high transection lesion of right and left hepatic duct, and we decided to do Roux-en-Y hepaticojejunostomy. We created a part of anastomosis between the jejunum and liver capsule with polydioxanone suture (PDS) 4-0 because of poor quality of the remaining parts of the hepatic ducts. We made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts, without Witzel enterostomy and transhepatic biliary stent. There were no significant postoperative complications. Magnetic resonance cholangiopancreatography (MRCP) was made one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses.

Discussion: In most cases, treatment iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent or creating duct-enteric anastomosis, often used and drainage by Witzel (Witzel enterostomy). Reconstructive hepaticojejunostomy is recommended for major BDIs during cholecystectomy. Considering that the biliary reconstruction with Roux-en-Y hepatojejunostomy is usually made with transhepatic biliary stent or Witzel enterostomy. What is interesting about this case is that these types of drainages were not made. We tried and managed to avoid such types of drainage and proved that in this way, without those types of drainage, we can successfully do duplex hepaticojejunal anastomoses and that they can survive without complications.

Conclusion: Our case indicates that this approach can be successfully used for surgical repair of iatrogenic lesion of both hepatic ducts.

Keywords: Iatrogenic bile duct injuries; Laparoscopic cholecystectomy; Roux-en-Y hepaticojejunostomy without Witzel enterostomy and transhepatic biliary stent.

Fig. 1

Preoperative CT of abdomen cavity. A CT of abdomen was performed, which showed extravasation of the contrast agent in the region of both hepatic ducts and presence of lesions of the left and right hepatic duct. It also showed presence of biloma and intraabdominal abscess collection (Fig. 1).

Fig. 2

Intraoperative duplex Roux-en-Y hepatojejunostomy. We performed the Orr incision to open the abdominal cavity. During the exploration we found high type (Class E) transection lesion of right and left hepatic duct, and we decided to do Roux-en-Y hepaticojejunostomy. Because of the lesion of the both hepatic ducts in the hilus of the liver, biliary peritonitis and poor quality of the remaining part of the hepatic ducts, we created a part of anastomosis between the jejunum and liver capsule with polydioxanone suture (PDS) 4-0 without Witzel enterostomy and transhepatic biliary stent. We made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts (portoenterostomia) (Fig. 2). After that we made entero-entero anastomoses to continue the continuity of the digestive tube. With the evacuation of the abscess collections, the abdominal cavity toilet and the placement of abdominal drain, we completed the surgical procedure.

Fig. 3

MRCP one year after surgery procedure. We did magnetic resonance cholangiopancreatography (MRCP) one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses (Fig. 3).