Two-stage laparoscopic approach for a bile duct injury with a two-week biliary peritonitis

Marcel Sanhueza, MD¹, Rose Marie Mege, MD¹, Eduardo Vinuela, MD¹, Eduardo Briceno, MD¹, Cristian Diaz, MD¹, Constanza Godoy¹, Gustavo Carvalho, MD, PhD², Julian Varas, MD³, Nicolas Jarufe³, Alfonso Diaz, MD¹. ¹Complejo Asistencial Dr. Sotero del Rio de Chile, ²Faculty of Medical Sciences, University of Pernambuco, Recife, Brazil, ³Department of digestive surgery, Pontificia Universidad Catolica de Chile

The Objective of this video is to present how a complex case of a Bismuth-Strasberg E2 biliary injury with an associated biliperitoneum was resolved with a pure laparoscopic two-stage approach starting at postoperative day 10. The surgical team involved in this case has over 10 years of advanced HBP laparoscopic experience.

Case: A 56-year-old female to whom a laparoscopic converted to open cholecystectomy for acute cholecystitis was performed. The patient was discharged at postoperative day 3 uneventfully. Ten days after surgery the patient was readmitted for abdominal pain, nausea, jaundice and having signs of peritoneal irritation on physical examination. Abdominal ultrasound indicated pelvic free fluid, suprahepatic collections and a dilated intrahepatic biliary tract raising the suspicion of a major bile duct injury with associated biliary peritonitis.

Stage 1, Exploration and Lavage:

In order to avoid adding with a large laparotomy a huge inflammatory response to the already established septic process, a laparoscopic exploration and lavage was performed. After a successful open umbilical pneumoperitoneum, a first inspection revealed an extensive biliary peritonitis with severe adhesions and subphrenic collections. Once careful adhesiolysis using blunt dissection was performed, a bile leak from the main biliary tract was observed and a drain was left in place next to it, in addition to two other drains left in both subphrenic spaces.

The bile leak drain conducted the hepatic clearance for three weeks till it stopped and the patient progressively accumulated serum bilirubin.

From this point on, and given the favorable evolution of the patient, the surgical team decided to complete a six weeks period after stage one intervention in order to favor a better surgical outcome for a second laparoscopic exploration.

Stage 2, Reconstruction:

An open pneumoperitoneum was again made this time trough the right flank to avoid possible adhered bowel to the abdominal wall as suggested by CT-scan controls. The exploration showed no evidence of residual collections and most adhesions found were loose. Using blunt dissection all these adhesions were freed until the hepatic pedicle was clearly identified. A special effort was made to release the stomach and duodenum from the pedicle in order to have a clear view of the portal vein bifurcation and the understanding of the altered anatomy of the biliary tract. The common bile duct was ligated and completely transected at 1 cm from the confluence.

Preparation of Roux-en- Y anastomosis with a short transmesocolic biliary limb was created. The biliary confluence for an end-to-side hepaticojejunostomy was accessed by sectioning and removing the scar tissue on the proximal common bile duct stump. After the bile-diversion was performed all gap spaces were closed.

Postoperative course was uneventful and the patient discharged at the fourth day.

Conclusion: A two-stage approach in order to face with a two-week biliary peritonitis secondary to a iatrogenic bile duct injury is feasible an may favor the evolution to a less dramatic solution for this complex scenario.