Presentation
Surgical history: cholecystectomy with complication of common bile duct rupture. A drain was placed for bile duct bypass with a T tube and the gallbladder was removed. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, resulting in total occlusion of the common bile duct in the distal third by two perpendicular staples. In addition, a sphincterectomy was performed without success.
Patient Data
1 month post cholecystectomy
In the arterial phase, the common hepatic artery was identified in the hilum without identifying right and left intrahepatic branches. T-tube entering the right ventral abdominal wall, with a subhepatic trajectory and reaching the common bile duct.
A bypass catheter was placed with entry to the left biliary branch to the convergence of the common hepatic duct, and exit through the left anterior abdominal wall to the collecting bag.
In the portal phase, diffuse hypodense areas are observed, predominantly in the right lobe. In addition, more hypodense images with defined edges are visualized are displayed inside in relation to dilatation of the bile duct.
In the coronal projection, surgical material of metallic density (staples) is identified at the level of the common bile duct.
As additional findings, bilateral pleural effusion and pericolonic abdominal free fluid are documented.
Anterograde cholangiography using fluoroscopy, the left bile branches are approached by a multipurpose catheter, identifying dilatation of the intrahepatic bile duct, without passage of contrast to the common bile duct, observing at least nine staples in its topography.
Case Discussion
The incidence of bile duct injuries in laparoscopic cholecystectomy is very rare.
The diagnosis of bile duct injury is made in most cases in the postoperative period. The most widely used classification internationally in bile duct injury is the Bismuth classification. Due to the characteristics of the lesion in this case, it is classified as type E4.
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