Surgical management of iatrogenic bile duct injury in patients with atypical ductal anatomy

摘要

Bile duct injury after laparoscopic cholecystectomy is a feared complication with significant morbidity and mortality. Bile leak is more common in laparoscopic cholecystectomy versus open (0.5–3% vs 0.1–0.5%, respectively). More than three-fourths of bile duct injuries are not recognized at the time of surgery; symptoms (including pain, fevers, nausea, and vomiting)typically present three to six days after surgery, although late presentation up to 90 days after surgeryhas been reported.1 On laboratory workup, there may be elevation in alkaline phosphatase and bilirubin, consistent with cholestasis, or even elevated liver function tests.1 On radiologic workup, CT is more sensitive than ultrasound to detect fluid collections. Risk factors for bile duct injury include anomalous anatomy and anatomic distortion secondary to chronic or severe inflammation, and the most common cause of injury is incorrect interpretation of anatomy.2 Bile duct injury is avoided by complete circumferential dissection of the gallbla dder neck and cystic duct before clip placement and ligation.