Simultaneous Damage to the Hepatic Artery and Common Bile Duct in a Blunt Abdominal Trauma: A Case Report

Background: Diagnosis and management of extrahepatic duct injuries in blunt abdominal trauma is very difficult and challenging. First because these injuries are very rare. Also, in the management of abdominal blunt trauma, many patients are currently managed with non-surgical and conservative methods. Case presentation: A 23-year-old man who referred to General Hospital in down town of Tehran due to severe trauma in rollover motorcycle accident. There was no evidence of hemodynamic instability in emergency department. There was a drop in hemoglobin in the first week of hospitalization, which could be due by hepatic artery injury. We decided to manage hepatic artery pseudo aneurysm with interventional radiology approach. On angiography, a picture of a thrombotic pseudoaneurysm was seen, which was embolized by passing a catheter and endovascular coiling. Four days later, he presented with severe abdominal distension. In the study, the abdomen was full of fluid, which was emptied, and about 5 liters of bile were expelled. Twenty-four days after the accident, the patient underwent ERCP and a clear leak of proximal part CBD was evident. CBD stent was inserted under the guide of fluoroscopy. The patient underwent complete intravenous nutrition and the volume of discharge did not decrease during treatment. One week after starting intravenous feeding, the patient developed fever, tachycardia, and abdominal tenderness, so he underwent surgery. Severe adhesions and multiple collections were evident in the abdomen. Abdominal lavage was performed and two right and left sub-diaphragmatic drains were inserted and the abdomen was closed. Enteral feeding began 5 days after the surgery and the patient was discharged in good general condition. Conclusions: This is a rare case of simultaneous hepatic artery and common bile duct injury at the same time which manage with interventional embolization for hepatic artery pseudoaneurysm and ERCP and stenting also total parenteral nutrition for common bile duct injury at first step. At last surgery was done due to control the sepsis and abdominal collections drainage.

Bismuth Classification of Bile Duct Injury and Its Association with Increasing 30 Days Mortality after Revision Surgery

Background: The incidence rate of bile duct injury has not been changed for many years for both open or laparoscopic technique. Open cholecystectomy has risen from 0.5% to 1.4% when gallbladder removal is performed laparoscopically. Injuries of the bile duct system after laparoscopic cholecystectomy are more complex than that after an open approach, causing significant morbidity and even death. From initial classification published by Bismuth, there have been many classifications of common bile duct injury. We would reported the 30 days mortality rate following reconstruction after bile duct injury according to type of Bismuth classification. Case Report: 7 cases of common bile duct injury were reported from 2016 until 2018 following cholecystectomy (both open and laparoscopic), all cases were diagnosed as early complication and without intra operative cholangiography performed. The most common bile duct injury was Bismuth type II and IV (2 patients in each type). Reconstruction has been done by hepatico jejunostomy for type III and IV. Choledoco Duodenostomy bypass was done for type I and II. 2 patients with bismuth type IV have long standing cholangitis and cannot survive during 30 days of follow up. 4 others patients could survive with no intra abdominal complication nor other morbidity. Conclusion: Bismuth classification was the simpliest type to described the bile duct injury, Bismuth type IV was associated with the high risk of 30 days mortality rate. Keywords: bismuth classification, bile duct injury, cholecystectomy, mortality

Introduction of paediatric laparoscopic cholecystectomy in Scotland: a national review of incidence, outcomes and training implications

Background We present a national data series to determine the incidence, outcomes and training opportunities for laparoscopic cholecystectomy among children <16yrs in Scotland as performed by paediatric surgeons. Methods A retrospective cohort study was performed reviewing laparoscopic cholecystectomy performed at the three children’s hospitals in Scotland. Using the National Records Scotland Database mid-year population estimates; age and sex specific annual incidence rates of laparoscopic cholecystectomy were calculated between 1998-2015. Trends in the observed case mix were tested using univariate linear regression and students t-test. Results Between 1998–2015; 141 paediatric laparoscopic cholecystectomies were performed. The annual rate of cholecystectomy increased from 0.10/100,000 to 0.88/100,000 (p = 0.069). Sex specific incidences were identified; 0.00–0.90/100,000 (p = 0.098) in girls and 0.20–0.86/100,000 in boys (p = 0.28). Cholecystectomy was more frequent in girls (63%; p = 0.04). No major complications, defined as common bile duct injury or mortality were identified. Overall; 75% of cases were performed by consultants (n = 17 consultants, median = 5 cases, p < 0.05) and 25% by trainees. Conclusion We have demonstrated that despite a low national case load (8 laparoscopic cholecystectomies per year) paediatric surgeons have been able to perform laparoscopic cholecystectomy safely without major morbidity.

Micro-Dosing of Indocyanine Green for Intraoperative Fluorescence Cholangiography

Background: Surgery involving the biliary tree is common but has the potential for serious complications. Adjuncts such as intraoperative cholangiogram and, more recently, indocyanine green (ICG) fluorescence cholangiography, have been used to more accurately define the relevant anatomy and decrease the risk of common bile duct injury. The optimal ICG dose is unknown, but the most commonly cited dose in the literature is 2.5 mg. We describe our experience using micro-dosing of ICG as proof-of-concept for its successful use in the identification of biliary structures. Methods: A video library from a variety of hepatobiliary surgeries which included micro-dosing of ICG was compiled between 2018 and 2020. These videos were retrospectively reviewed and graded for the degree of visualization of biliary structures (complete, partial, none) and the degree of background liver fluorescence (significant, moderate, minimal). Results: Overall, 40 videos were reviewed; 70% were minimally invasive cholecystectomies. Micro-dosing was used in all patients; complete visualization was achieved in 52.5% of the patients, partial visualization in 40%, and no visualization in 7.6%. Eighty percent of patients had minimal to moderate background fluorescence. Despite ICG micro-dosing, 20% of the patients still had significant liver dye uptake. Conclusion: ICG cholangiography is an alternative to more invasive means of intraoperative imaging during biliary surgery, but the optimal dose of ICG is unknown. We have used a 0.05 mg micro-dose of ICG to successfully visualize biliary structures and reduce background liver fluorescence. This preliminary report can be used to develop further studies into whether micro-dosing of ICG is associated with improved clinical outcomes.

Small Bowel Adenomyoma: An Incidental Intraoperative Finding While Performing Hepaticojejunostomy for CBD Injury

Adenomyoma is a benign lesion that is most commonly seen in the gallbladder, however, rare cases have been reported where this pathology was encountered in the vicinity of the gastrointestinal tract. The pathogenesis of this lesion is still a controversy, with the previous reports suggesting it to be either a form of hamartoma or incomplete heterotopic pancreas. Jejunal and ileal adenomyoma have been rarely reported, and as of 2016 less than 30 cases were reported in the English literature. The clinical presentation is variable depending on the location of the lesion. Although there are no specific management guidelines for this pathology, a surgical resection is sufficient. However, aggressive surgical approaches, such as pancreaticoduodenectomy for periampullary adenomyoma, have been undertaken in the previous reports due to the misdiagnosis with carcinoma preoperatively. We report a case of a 58-year-old gentleman who was referred to our Hepato- Pancreato-Biliary facility with common bile duct injury post laparoscopic cholecystectomy for hepatico- jejunostomy. Intra-operatively, an intra-luminal, jejunal mass was found measuring 2x2 cm and was about 95 cm from the DJ junction. The lesion was resected with safety margins, and primary anastomosis was done. The final histopathology of the specimen was consistent with adenomyoma, and all of the surgical margins were free.

Omentoplasty Combined With Endoscopic Stenting in the Treatment of Lateral Duct Injury at Hepatic Duct Bifurcation

Background Common bile duct injury (CBDI) is a devastating complication from laparoscopic cholecystectomy. The endoscopic retrograde cholangiopancreatography (ERCP)-based sphincterotomy and stenting were reportedly effective in treating low or distal lateral CBDI. However, in the circumstance of proximal lateral CBDI, the routine biliary stent may not provide coverage of the leak site, which posed a unique clinical challenge when such proximal CBDI occurred. Methods This patient is an 85-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis. The gallbladder was contracted and atrophic with extensive dense adhesions in the infundibular area. A dome-down approach was attempted, and a small side hole was identified from a tubular structure with minimal bilious leakage. The intraoperative cholangiogram showed a bile leak at the hepatic duct confluence. A vascularized omental patch was fashioned and secured to the vicinity of the CBDI in a tension-free manner. Two drains were placed. ERCP and endoscopic stenting were undertaken the following day. Results There was minimal bilious fluid output from the Jackson-Pratt drains in the first 24 hours. This was reduced further following ERCP and resolved in 2 days while tolerating a regular diet. All laboratory studies were normal. The drains were removed week postoperatively. The patient was seen in the clinic at 12 months, and there was no evidence of bile leak or stricture. Conclusion The combination of omentopexy and endoscopic stenting is safe in managing high lateral bile duct injury. Prospective studies are needed to further validate this technique.

A prospective observational analytical study on Rouviere’s sulcus: a single institutional study

Background: Laparoscopic cholecystectomy is the most commonly performed laparoscopic surgery worldwide. Safe cholecystectomy is the priority to reduce the morbidity and mortality. There is a paradigm shift from extensive Calot’s dissection to identification of Rouviere’s sulcus and lesser dissection. Identification and analysis of Rouviere’s sulcus will help us doing a safe cholecystectomy and avoiding further injuries to bile ducts.Methods: The study included 160 cases of laparoscopic cholecystectomy, posted in elective OT and identified Rouviere’s sulcus during laparoscopy. Table visual inspection and analysis was done. And the collected data was analyzed for different types of sulcus, its position, morphology and content.Results: Of 160 cases, 147 cases had Rouviere’s sulcus. 13 cases did not have a sulcus. Open type sulcus was present in 99 cases, 35 had closed type, whereas 19 had slit type and only 7 had a scar like sulcus. The study showed 92% of our patients had Rouviere’s sulcus and of them 61.9% had an open type which was the most common type of sulcus of them 18 cases had a visible pulsating vessel in the floor of the sulcus i.e. posterior sectional pedicle in the sulcus.Conclusions: Present study showed, in 92% cases it is easy and approachable to visualise the Rouvier’s sulcus. So, it is feasible and beneficial to identify the sulcus and keep the dissection above this level to avoid common bile duct injury and further complication thereof.