Complex Roux en Y double hepaticojejunostomy following a sequalae of iatrogenic bile duct injury; case report

Abstract

Introduction and importance: Obstructive jaundice following iatrogenic biliary injury is a rare but serious complication, often resulting from procedures such as laparoscopic cholecystectomy. It poses significant diagnostic and therapeutic challenges due to its complexity and potential for life-altering sequelae. Timely recognition and management are essential to prevent long-term morbidity. This report highlights the clinical course and successful surgical management of a complex biliary injury, underscoring the importance of advanced imaging, timing and prompt intervention.

Case presentation: A 53-year-old woman presented with a one-month history of obstructive jaundice, progressive pruritus, pale stools, and dark urine. She denied pain or systemic symptoms. Her medical history included a laparoscopic cholecystectomy six months earlier, complicated by biliary peritonitis, which necessitated an exploratory laparotomy. Imaging revealed extensive biliary disruption, including absence of the common hepatic duct and a laceration of the left hepatic duct. Surgical reconstruction was performed using a Roux-en-Y hepaticojejunostomy. Postoperatively, the patient had an uneventful recovery, with significant clinical improvement and normalization of liver biochemistry.

Clinical discussion: Iatrogenic biliary injuries, though uncommon, can result in significant morbidity. Early recognition through clinical suspicion and advanced imaging modalities is crucial for accurate diagnosis. Surgical intervention, particularly hepaticojejunostomy, remains the cornerstone of treatment for extensive biliary disruption, offering durable outcomes and resolution of symptoms.

Conclusion: This case underscores the importance of vigilance in diagnosing and managing complex biliary injuries. Multidisciplinary collaboration, advanced imaging, and timely surgical repair are key to achieving favorable outcomes in such challenging cases.

Keywords: Biliary peritonitis; Iatrogenic bile duct injury; Laparoscopic cholecystectomy; Obstructive jaundice; Roux-en-Y hepaticojejunostomy; Strasburg‑bismuth classification.

Fig. 1

ERCP image showing A - coiled guided wire in the CBD due to proximal obstruction, B - normal caliber CBD, and C - endoscope in the second part of duodenum.

Fig. 2

Moderate IHBRD with normal CBD caliber. The confluence of the hepatic ducts is visualized. Yet, the CHD is not.

Fig. 3

a. Intraoperative image showing A - remnant of left hepatic duct, B - middle branch of hepatic artery proper and C - hepatic artery proper. b. Intra-operative image showing D - remnant of left hepatic duct anterior wall, E - left branch of portal vein, and F - left branch of hepatic artery proper.