Adolfo Cuendis, MD1, C Morales, MD2, M Rojano, MD1, M Mucio1, I Aguirre1, F Torres1, Lc Fernandez3. 1Hospital GEA, 2private practice, 3SSA
The case:
Female 44 years old. Open cholecystectomy with bile duct injury Strasberg E1 and end to side hepaticojejunostomy was performed three days after cholecystectomy.
Develops jaundice, fever, upper quadrant pain, itching and several cholangitis episodes one month after index surgery. She was referred to our center two years later.
At the pre-op workup CMR shows obstruction of the hepaticojejunostomy, intrahepatic stones and massive bile duct dilatation.
Laparoscopic approach was performed, finding multiple adhesions. Dissection was performed until the liver edge was found and subsequently adhesions in hepatoduodenal ligament were dissected too, exposing the hepaticojejunostomy.
Puncture cholangiography was performed to ensure the site of hepaticojejunostomy; the cholangiogram coincided with CMR.
The jejunojejunostomy was dissected to ensure it was the biliary loop.
The hepaticojejunostomy was transected and anterior ductotomy was extended into common hepatic duct, extracting multiple common bile duct stones and sludge. Washing was made with saline and intrahepatic calculi clearance was performed under direct vision using an Olympus 180 gastroscope aided by endoscopic extraction balloon until proper confirmation of the bile duct clearance.
Then we proceeded to debride remaning scar tissue of prior anastomosis and extend the anterior ductotomy through the common and left hepatic duct. The edge of the biliary limb was stapled and excised.
Wide enterotomy was done, then a new latero-lateral Hepp-Couinaud-like hepaticojejunostomy was built with separate stitches of absorbable monofilament and extracorporeal sliding knots.
Operative time was 200 min an bleeding 250cc. No complications where developed in post operatory period. She started oral intake after 24 hrs. The hospital stay was 4 days.
The control CMR shows significant decrease of dilatation and absence of intrahepatic stones. Ten months later the patient remains asymptomatic with normal liver function tests.
The simultaneous laparoscopic and endoscopic approaches even in complex cases like this one, seems to be the best option for our patients; combining the two techniques, we can overcome the limitations of each separate approach. Offering the benefits of minimally invasive approaches even in this pathologies proves to be a feasible and safe technique.