categorization of the type of MBDI are the next steps. Once this is done, definitive repair of the injury should be performed. Postoperative follow-up and guidance, are vital parts of this prolonged treatment protocol. The reported incidence of MBDI afterlaparoscopic cholecys- tectomy has been shown to be higher than that after open cholecystectomy . Several risk factors have been identi- fied, mainly dangerous pathology, dangerous anatomy, and dangerous surgery . In spite of the recognition of these well established risk factors, MBDI continues to be a problem in laparoscopic surgery. Furthermore, it may be missed during laparoscopiccholecystectomy . During cholecystectomy, much emphasis is given to com- plete exposure of the operating area. During the exposure of peritoneal attachments in Calot's triangle, anatomical variations should be clearly identified, and the cystic duct should not be separated until the junction of the common hepatic and cystic ducts is positively identified. There is no confluence of any other abnormal ducts into the cystic duct.
Gallstone disease is one of the most common digestive health problems (Nakeeb et al., 2002). Laparoscopiccholecystectomy (LC) is now the gold standard for gallbladder removal in the management of symptomatic cholelithiasis with decreased postoperative morbidity and mortality. Still, bileduct injuries are reported to be more severe and more common when compared to open cholecystectomy (Sicklick et al., 2005; Rauws, 2004; Ponsky, 1991; Deziel et al., 1993) with a reported incidence of up to 0.6% for laparoscopic versus 0.1% for open cholecystectomy (Deziel et al., 1993). These injuries are a disaster for both the patient and the surgeon because of the associated morbidity, prolonged hospitalization, and mortality (Kaman et al., 2004). The management of patients following majorbileductinjury is a surgical challenge often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers (Branum et al., 1993). Collaboration among surgeons, gastroenterologists and interventional radiologists is imperative in the care of such injuries. The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of a case with major complex bileductinjuryafter LC
Laparoscopiccholecystectomy (LC) has been recently adapted to acute cholecystitis. Majorbileductinjury during LC, especially Strasberg-Bismuth classification type E, can be a critical problem sometimes requiring hepatectomy. Safety and definitive treatment without further morbidities, such as posthepatectomy liver failure, is required. Here, we report a case of severe bileductinjury treated with a stepwise approach using 99m Tc-galactosyl human serum albumin ( 99m Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging to accurately estimate liver function. A 52-year-old woman diagnosed with acute cholecystitis underwent LC at another hospital and was transferred to our university hospital for persistent bile leakage on postoperative day 20. She had no jaundice or infection, although an intraperitoneal drainage tube discharged approximately 500 ml of bile per day. Recorded operation procedure showed removal of the gallbladder with a part of the common bileduct due to its misidentification, and each of the hepatic ducts and right hepatic artery was injured. Abdominal enhanced CT revealed obstructive jaundice of the left liver and arterial shunt through the hilar plate to the right liver. Magnetic resonance cholangiopancreatography revealed type E4 or more advanced bileductinjury according to the Bismuth-Strasberg classification. We planned a stepwise approach using percutaneous transhepatic cholangiodrainage (PTCD) and portal vein embolization (PVE) for secure right
Abstract: Background: This study details Assiut and South Valley universities experience in treating combined gall bladder and common bileduct stones in a single session, either with Endoscopic Retrograde Cholangio-Pancreatography (ERCP) for Common BileDuct (CBD) stone extraction followed by laparoscopiccholecystectomy (LC), or totally laparoscopic treatment. Patients and methods: In this prospective randomized study, 46 consecutive patients with confirmed cholecysto- choledocholithiasis were randomized to 2 groups. Group (A) included 24 patients treated with single-session ERCP for CBD stone extraction and laparoscopiccholecystectomy [ERCP-LC]. Group (B) included 22 patients treated with laparoscopic CBD exploration and laparoscopiccholecystectomy [LCBDE-LC]. Demographic data, operative time, CBD clearance success rate, short term complications and duration of hospital stay were recorded. Results: Patients included 28 females and 18 males with mean age of 42.1 ± 12.1 years (range 17 – 71 years). In 22/24 patients (91.7%) ERCP-LC was done successfully. Mean operative time was 105 ± 19.1 minutes (50-150 min.). No intra-operative complications occurred. Early post-operative complications occurred in 3 patients (12.5%). Mean hospital stay was 2.1 ± 0. 91 days (1-6 days). In the other group, LCBDE- LC was performed successfully in 22/22 patients (100%). Mean operative time was 145 ± 23 minutes (100-180 min.). Minor intra-operative complications (bleeding) occurred in 2/22 cases (9%). Minor early post-operative complications (bile leak, ileus, bleeding) occurred in 4/22 patients (18%). Mean hospital stay was 2.8 ± 0.83 days (2-7 days). Conclusion: Single session ERCP-LC and LCBDE-LC procedures for management of cholecysto-choledocholithiasis are feasible, safe, and effective and have comparable outcome regarding success rate, peri-operative complications. ERCP-LC has statistically significant less operative time and less hospital stay.
Symptoms may appear more readily in early-stage remnant CDC than in gallbladder cancer. The cystic duct obstruction may cause symptoms like abdominal pain and jaundice as the gallbladder becomes distended, ultimately resulting in cholecystitis with fever, chills and inflamma- tion . Sakurai et al.  documented a case of early CDC, in which invasion was restricted to the fibromuscu- lar layer; the papillary tumour projected into the common bileduct, remote from the junction of the cystic duct, to reach the common bileduct, causing obstructive jaundice. However, in the present case of a remnant CDC, the latter symptoms were jaundice and concomitant haemobilia, which was difficult to diagnose by conventional radio- logical modalities. In contrast, bleeding pseudoaneurysm of the cystic artery due to chronic cholecystitis treated by endovascular embolization and subsequent cholecystec- tomy have been well designated . We noticed that the originating site of haemobilia was itself a tumour (Figs. 4 and 5 a). This is quite a rare phenomenon, with little published literature pertaining to this clinical feature.
particular attention has been paid to the introduction of air peritoneum and the insertion of trocar, since their incorrect positioning can also give rise to significant complications. Before starting the gallbladder dissection, it is fundamental to find the triangle Of Calot; If it is not located within 20 minutes, you opt for a conversion. Once the Calot triangle is delimited, the surgeon locates the cystic duct, the biliary and the vascular structures; In cases of anomalous presentation, the question arises whether to continue the operation in a videoaparoscopic method, or if an open reconversion is required. Same procedure for the detection of important adherence phenomena. In the case of misinformation, not seen by previous imaging examinations, the patient underwent intraoperative cholangiography in order to provide a clearer anatomical framework. In the case of possible operative complications, reconversion necessarily presents a higher chance of successful intervention than a laparoscopic approach; The surgeon's decision came from A careful assessment that included the degree of injury, the state of the operating field, the technical-instrumental repair option, the general clinical condition of the patient, and, above all, a sincere analysis of their technical capabilities (25,26,27,28). Another important aspect is the monitoring and management of the post-operative course, it is Drainage if placed. The positioning of the drainage level at the liver lobe if we decide the attachment was maintained for 24-48 hours, in our experience so we can also report the minimum leakage within that timed window, optimal for a better repair result in case Of complications. Depending on the extent of the leak loss from bileduct drainage. There can be a history
The incidence of bileductinjury in laparoscopiccholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dis- sected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 fe- males and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopiccholecystectomy. The mean operative time was 60 minutes (between 40 and 90 mi- nutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up pe- riod (20 months). Bipartite laparoscopiccholecystectomy is safe, easy to do, and can avoid all com- plications especially bileduct injuries in difficult cases.
Laparoscopiccholecystectomy is now a gold standard treatment modality for symptomatic gallstone diseases. However, the incidence rate of bileductinjury has not been changed for many years . This may be because of biliary tree abnormalities, as variation in cystic duct anatomy is quite common, which may be detected by preoperative ultrasonography, magnetic resonant cholangiopan- creatography  .
This agree with Boerma et al. study, in which open surgery (cholecystectomy and bile-duct exploration) with endoscopic sphincterotomy alone were compared, 20% of patients managed expectantly after sphincterotomy needed cholecystectomy during follow-up, and in another study, single-stage laparoscopic surgery (laparoscopiccholecystectomy and bile-duct exploration) was shown to be better than a two-stage procedure of endoscopic sphincterotomy and subsequent laparoscopiccholecystectomy, because of a shorter admission time (Djemila Boerma, 2002). Based on our results, it seems that the high cholecystectomy- on-demand rate of 18.0% (9/50) in our study could be related simply to the fact that all patients included had radiologically proven gallbladder stones, which is a suggested risk factor for recurrent symptoms. These observations would be consistent with previous studies (Nielsen, 2014). Also Boerma, et al.,(2002) reported cholecystectomy on demand in about 30% of uncomplicated cases. Major complications developed in one of 22 operated patients in the wait-and-see group (intra- abdominal abscess, 4·5%) and in three of 44 patients in the
In case of a partial transection of the common bileduct recognized at the time of initial surgery, primary repair over a T-tube gives good outcome. Fine, monofilament, absorbable sutures should be used for the repair and the T-tube brought out via common bileduct at a distant site away from the repair site . One study reported a restricture rate of nearly 100% for end-to-end repairs of the common bileduct especially if the injury is secondary to the use of cautery or results in complete transection of the duct . These patients are best managed with a biliary-enteric anastomosis as later described. However, Stewart and Way indicate success of repair does not depend on timing of repair but rather depends on eradication of bilioma, , use of a single layer end- to-side hepaticojejunostomy with fine absorbable suture, and severity of Stewart-Way injury class.
and affect the recovery of patients [26, 27]. This may also be a reason why patients are more satisfied with nasobiliary drainage. The analysis of liver function in the two groups showed that both treatments did not cause abnormal liver function in patients. There was no statistically significant difference in liver function between the two groups after sur- gery. Analysis of the complications in two gr- oups showed that there was no difference in the incidence of complications between the two groups. Studies have reported that the in- cidence of postoperative complications as- sociated with T-tubes is about 10%, which is similar to our findings [28, 29]. Many studies have reported that the friction of T-tube may cause duodenal injury, continuous bile leakage or T-tube slippage displacement, leading to biliary obstruction, bile leakage or infection around the tube, and hydroelectrolytic disor- ders caused by massive bile loss [30, 31]. Therefore, surgeons began to explore the pri- mary suture technique of the common bileduct and other drainage methods. The nasobiliary drainage not only avoids the defects of the T-tube, but also solves the problem of biliary hypertension and biliary inflammatory edema after primary suture, with significant advantag- es . However, there are still some shortcom- ings in this study. The number of cases includ- ed was small, and there were some differenc- es in endoscopic operators. The results still require more multicenter randomized controll- ed trial to support.
Some of these ducts may drain substantial portions of the right lobe of the liver, either one of the sectors (two segments) or a segment and may in fact be the sole drainage of that part of the liver in which case they are more precisely termed as 'aberrant' ducts. It has been suggested that most such ducts are aberrant rather than accessory in which case it is even more important to safeguard them. If such a duct is injured it can lead to substantial biliary stasis or leak. The size of the duct may be an indirect indicator of the amount of liver it drains. It has hence been recommended that in case of injury if the duct is more than 3 mm it should always be drained into a Roux loop. Alternatively one can perform a cholangiogram through the duct to assess the amount of liver it drains as well as whether it is accessory or aberrant. With increasing recognition of injury to such ducts these have now been grouped into separate type in the recent Strasberg classification of bileduct injuries.
Laparoscopiccholecystectomy is widely established as the standard operation in acute cholecystitis .The traditional teaching has been a two stage treatment for acute cholecystitis with an initial conservative management followed by an interval laparoscopic cholecystectomy.Laparoscopic cholecystectomy is avoided for acute cholecystitis due to concerns about the potential hazards of complications,especially common bileductinjury and a high conversion rate to open cholecystectomy.The conversion rates for elective laparoscopiccholecystectomy range from 3-7 %.However in presence of acute inflammation ,higher conversion rates of up to 30 % have been reported.Several studies have reported favourable outcomes with a low conversion rate if patients are operated within 96 hours of admission.[4,6]
For the control group, endoscopic management of CBD stones was performed under intravenous sedation using a side viewing endoscope (TGF 160). After visualizing the papilla, cannulation was done using a sphincterotome, followed by retrograde cholangiography, sphincterotomy and stone extraction using either a basket or by ballooning. In case of large stones, mechanical lithotripter was used to crush the stones before removal. After stone extraction, a check cholangiogram was performed to look for residual stones. Temporary stenting of the common bileduct was done if the stone clearance was incomplete. If there were no signs of complications, all patients underwent laparoscopiccholecystectomyafter 48 hours but within four weeks of the endoscopic clearance.
Bileduct injuries are associated with significant morbidity, prolonged hospitalization, increased financial burden, potential litigation and occasional mortality. It is the third most common litigated general surgical complications in western statistics, also it has been reported that average two procedures (between 1 to 8) are required for definitive repair of bile ducts. Bileductinjury if fortunately identified and repaired peroperatively, carry less morbidity and mortality.
In conclusion, a CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were significant pre- dictive factors for recurrence after endoscopic extraction of CBD stones. For patients with risk factors for bileduct stone recurrence, periodic surveillance may be recommended. In addition, prophylactic cholecystectomyafter clearance of CBD stones does not appear to reduce the incidence of recurrent CBD stones in Korean patients, in whom pigment stones are more common. Further prospective studies are needed to in- vestigate long-term outcomes in these patients.
Case presentation: A 70-year old man was diagnosed with gallbladder cancer and received open cholecystectomy with lymphadenectomy at a local hospital. Histologically, the tumor was localized in the mucosal layer, and no lymph node metastases were found. Three months later, hilar bileduct stricture due to delayed bileduct ischemia was found. Then, biliary drainage was performed with endoscopic biliary stenting. Three months later, the patient experienced cholangitis with septic shock, and percutaneous transhepatic biliary drainage (PTBD) into the left intrahepatic bileduct was performed. Unexpectedly, the aspiration bile cytology of the PTBD catheter showed malignant cells, and the patient was referred to our clinic for possible surgical treatment. According to additional studies, the hilar bileduct stricture was 3 cm in length. None of the imaging studies detected malignant cells in the bileduct around the hilar stricture. The left portal vein was obstructed due to inadvertent puncture of the PTBD. No findings indicated cholangiocarcinoma. We performed left hepatectomy with caudate lobectomy and extrahepatic bileduct resection. The postoperative course was uneventful. In the final pathology, flat type in situ carcinoma was found at the confluence of the right and left hepatic ducts, which was distant from the biliary stricture.
Perforations caused by swallowed foreign bodies at the duodenum are particularly interesting once it may not cause peritonitis but migration to adjacent organs such as pancreas, liver, and retroperitoneum . Some reports describe hepatic abscesses caused by FBs. Usually, the object is metallic and sharp, but there are more than 15 case reports of toothpick migration to the liver leading to hepatic abscesses . Surgical treatment for such disorder is mandatory . Differently, pancreatic migration of swallowed toothpick is much less common. Some reports describe complications such as pancreatitis, pancreatic hemorrhage and pancreatic pseudotumor [1, 22]. Migration to retroperitoneum is even rarer. Right psoas muscle abscess has already been reported as a complication of duodenal perforation .
The preoperative diagnosis was that of cholangiocarcinoma or other intraperitoneal tumor compression of the bileduct. We conducted an exploratory laparotomy and found a tough tumor located in the CBD, protruding from the wall of the bileduct to the right abdominal. The tumor was not completely blocking the bileduct lumen and there were no other tissues encroaching on the surrounding tissues, including the portal vein, hepatic artery, inferior vena cava, and pancreas. We excised the CBD 2 cm above and below the tumor with a hepatoduodenal ligament lymph node dissection. The Roux- en-Y anastomosis was conducted for the proximal bileduct and jejunum. The intraoperative pathology of the bileduct showed no tumor cells. The surgical resection specimen is shown in Figure 2.