Hem-o-lok clip found in the common bile duct 3 years after laparoscopic cholecystectomy and surgical exploration

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is a common and preferred choice for gallstone disease. Laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) are being increasingly used for managing choledocholithiasis and cholecystolithiasis. We report a case of a Hem-o-lok clip that was dropped into the common bile duct (CBD) after LC and surgical common bile duct exploration (CBDE). An 84-year-old man presented with right upper quadrant pain and jaundice for 2 months, and chills and hyperpyrexia for 1 day. The patient had received ERCP and surgical CBDE at a local hospital 3 years previously. The patient first received ERCP and endoscopic nasobiliary drainage (ENBD). When laboratory tests were normal, the patient then received LCBDE. During exploration, stones and a Hem-o-lok clip in the CBD were removed. The patient made good progress after LCBDE + T-tube placement and was discharged from hospital. The findings from this case suggest the following: 1) an appropriate therapy method should be considered for certain gallstone diseases, especially for choledocholithiasis and cholecystolithiasis; and 2) a Hem-o-lok clip should be carefully used during laparoscopic or robot-assisted surgery and the Hem-o-lok clip should not be in close proximity to the incision on the CBD.

Keywords: Gallstone disease; Hem-o-lok clip; cholecystectomy; cholecystolithiasis; choledocholithiasis; endoscopic retrograde cholangiopancreatography; laparoscopic common bile duct exploration.

Figure 1.

(a) Computed tomography shows dilation of the common bile duct (1.1 cm in width) and a calcified shadow (1.2 cm in length) in the upper common bile duct. (b) Computed tomography shows a calcified shadow (0.3 cm in length) in the end of the common bile duct.

Figure 2.

Endoscopic retrograde cholangiopancreatography shows an irregular filling defect in the upper common bile duct after extracting a stone in the end of the common bile duct. A nasobiliary duct was then placed in the common bile duct.

Figure 3.

Upper panel (a and b): during laparoscopic common bile duct exploration, two stones (0.6 × 0.5 cm in size) and a Hem-o-lok clip (0.2 × 0.8 cm in size) were found around the nasobiliary duct in the common bile duct. Upper panel (c) Two stones, a Hem-o-lok clip, and a ligature were removed. Lower panel: computed tomographic images show no stones in the common bile duct. Red arrow: location of T-tube placement.