Laparoscopic end-to-end repair of CBD injuries type E2

Metin Ertem, Professor, of, Surgery, MD, FACS1, Hakan Gok2, Emel Ozveri2. 1Istanbul Uni. Cerrahpasa School of Medicine, Istanbul, 2Acibadem Kozyatagi Hospital, Dept of Surgery, Istanbul

We present two cases related cbd injuries which occurred after laparoscopic cholecystectomy. We repaired these injuries with end to end anastomosis by laparoscopic techniques. We aim to share our experience of laparoscopic CBD injuries type E2.

In the first case; there were fourteen clips in the field. CBD was incised totaly, and closed with clips. All clips were removed except the artery clips. Both cut ends of the CBD was explored in the field. You have to draw the ends to touch each other easily in order to perform a tension free anastomosis. To free the cut ends is very important. Because, over dissection of the CBD may cause stricture.

Both of these injuries occurred after a laparoscopic cholecystectomy in two young women. Injuries were type E2. We were performed re-laparoscopic procedures 3 days after injury.

We used four ports for these operations. Two 10 mm and two 5 mm ports. We used cut mode of the electrocautery to apply bloodless dissection. Electrocautery should be used very low level in this field. Interrupted absorbable sutures should be used. We used 4/0 absorbable sutures. Care must ve taken that the knots must be outside of the lumen. After three stitches placed on the posterior wall of the duct, whole T tube is taken into the abdominal cavity. First, one leg of the t tube is placed through the distal orifice of the CBD. Insertion of the proximal leg of the t tube is quite difficult. One have to be patient. I can say that this manipulation is the most difficult part of the operation. After inserting the tube, two or three stitches are placed on both sides of the CBD. We prefer to repair with end to end anastomosis using t tube. T tubes were withdrawn after 12 days.

The operation was completed laparoscopically for all patients. No major complications were seen and the patients were discharged in 7th and 11th postoperative day, respectively.

In both cases, no late complication has occurred in the 2 years follow-up period.

We know that hepaticojejunostomy is not an innocent procedure. Also, There are long life expectancy in these young patients. In order to avoid negative consequences of the hepaticojejunostomy, we prefer end to end anastomosis which is more physiological repair. By doing so, we rule out a possible stricture.

Improved stent materials and endoscopic procedures have been developed in recent years. This gives us the courage to choose this repair technique. In these two cases we have not needed biliary stents. Extrahepatic bile duct interventions requires advanced laparoscopic skills and experience. This minimally invasive approach to extrahepatic biliary tract can be performed safely and reliably.Those operations should be done by skilled, experienced teams and at the fully-equipped centers So, Laparoscopic and especially robotic repair should be considered in such injuries.

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