Merseyside laparoscopic cholecystectomy course, Royal Liverpool Academy. The clinical cases to discuss.

1. LAPAROSCOPIC CHOLECYSTECTOMY:
COMPLICATIONS
Raimundas Lunevicius
Consultant Surgeon & Honorary Senior Lecturer
Emergency, Trauma, Biliary, Hernia Surgery
Aintree University Hospital NHS Foundation Trust, Liverpool, England
13th July 2018
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2. Case 1
Intraoperative cholangiogram
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3. 26-year-old female patient
• Presented with symptoms and signs of AC
• Emergency surgery
• Adhesions down
• Gallbladder well exposed
• Dissection of Callot’s triange
• 2 (tubular) structures entering GB exposed
• Quote from a clinical letter: ‘The 1st structure – cystic duct – lied
more posteriorly and it was continuous to the liver although it seemed to be
coming out of the GB’
• What would you do?..
3

4. Intraop-cholangiogram
Assumed to be CD
CBD: it turned out
CBD injury: Strasberg class D
Your further actions?..
Lunevicius R et all. Infundibular laparoscopic cholecystectomy method requires a quality renewal: 18 year 13 274
cholecystectomy analysis with assessment of 45 iatrogenic bile duct injuries. Lith Surg 2015; 14: 14-30
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5. 2nd opinion
Closure of the intraoperative cholangiogram opening
Subhepatic drain
Gallbladder left in situ
6 months later:
Open subtotal cholecystectomy, reconstituting type
Thoughts..
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6. Documentation
Injury to CBD has never been documented as
Injury to CBD
In summary:
classical example of CBD injury performing intraoperative
cholangiogram
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7. Case 2:
Severe abdominal pain following LC: Day 1
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8. • 32, female
• BMI > 42
• Known small gallstones
• EUS 4 months ago: CBD 5 mm, no choledocholithiasis
• Admission with biliary colic, normal LFTs
• LC: total
• large hem-o-locks in 1+1 fashion + two PDS loops on CD (no drain)
• Post op Day 1:
• Severe diffuse abdominal pain / peritonitic
• What would you do?
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9. Immediate CT-scan
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10. 10

11. Report
Radiology I:
There is a large right-sided
haematoma extending from the
right anterior abdominal wall all
the way down to the right rectus
sheath into the pelvis. In the right
anterior abdominal wall there is
acute oedematous and
inflammatory change.
What would be your questions to
me and management plan?
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12. Report
Radiology II:
There is extensive intra
and extrahepatic biliary
dilatation extending all
the way down to the
ampulla. It is difficult
to fully exclude an intra-
ductal filling defect.
Bilirubin: 99 micromol/L
B3
B4
B7
PSD
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13. RHD
ASD
CBD
Oedema
Oedema
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14. Post op D3: ERCP challenging: ST +
stent (no calculi identified)
No further complications, discharged
B8
B4
B2
B3
B7
B6
B5
B1
Main bile duct
B8
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15. This was the example of severe postoperative
abdominal pain (mimicking peritonitis) of dual origin
Super-large right rectus muscle hematoma
AND
Biliary colic secondary to choledocholithiasis
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16. Case 3.
• Intraoperative and postoperative management of sectional
bile duct injury during laparoscopic cholecystectomy
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17. Figure 1. Intraoperative cholangiogram via cystic duct
stump shows leak from narrow calibre bile duct
Opinion was expressed
by a surgeon and his
assistant that it is side
injury to one of the
sectional bile ducts.
Opinion denied by a
Consultant Surgeon
who was asked to come
to theatre
CHD
CBDCD
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18. Figure 2. Intraoperative cholangiogram via
drain in the injured bile duct
Drain in the sectional
(anterior) bile duct
Right hepatic duct
(RHD), left hepatic duct
(LHD), common hepatic
duct (CHD) and
common bile duct
(CBD) are intact.
CBD
CHD
LHD
T-tube
T-tube in the bile duct
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19. Figure 3. Postoperative cholangiogram
(post op day 48)
Drain in the anterior sectoral
bile duct.
Right hepatic duct (RHD),
left hepatic duct (LHD),
short common hepatic duct
(CHD) and long common
bile duct (CBD) are intact.
A stump of cystic duct is
well visible.
CHD
CD
CBD
T-tube in the bile duct
T-tube
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20. Figure 4. Postop CT-scan: Day 51:
arteries of right hemiliver
• Arterial supply of right hemi-
liver: artery supplying blood to
the right liver / right posterior
sections is well pronounced.
• It is a posterior sectional artery
or a variant of artery supplying
blood to the posterior (and
anterior, therefore) section of the
right liver. No evidence of hypo
perfusion. No signs of atrophy,
no signs of hypertrophy of the
liver. The last image shows
artery within anterior sector of
the liver.
• All postoperative LFTs of the
patient were within normal range
following his original surgery
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21. What you be your diagnosis and management plan?
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22. Figure 5. MRCP. 1.5 year post injury
after laparotomy and an attempt to perform Roux-Y anastomosis between
sectional bile duct and small bowel
This image shows full
disconnection between both
(not just one) sectional bile
ducts and right hepatic duct.
It also shows disconnection
between both (not just one)
sectorial bile ducts and
small bowel
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23. Figure 6. MRCP: 2.5 years later (Roux-Y surgery)
Full disconnection
between both sectional
bile ducts and right
hepatic duct remain
There is mild degree of
focal segmental
intrahepatic duct
dilatation in S5 and S8
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