General Surgery · Year 3 · from General Surgery

Case 2: Bile Duct Injury After Cholecystectomy

Patient Demographics

  • Age: 52 years
  • Sex: Female
  • Occupation: Real estate agent

Chief Complaint

"I've been leaking fluid from my drain site and turning yellow since my surgery 5 days ago."

History of Present Illness

The patient underwent laparoscopic cholecystectomy for acute cholecystitis at an outside hospital 5 days ago. The operative note reported a "difficult" case with significant inflammation. A drain was placed. Postoperatively, the drain initially had serosanguinous output, but over the past 2 days, the output has become bilious with increasing volume (now 400 mL/day). She has developed progressive jaundice, pruritus, and pale stools. She is transferred to your tertiary care center for evaluation.

Past Medical History

  • Acute cholecystitis (treated with cholecystectomy 5 days ago)
  • Hypertension
  • No other surgeries

Physical Examination

  • Vitals: BP 128/76 mmHg, HR 88 bpm, Temp 37.2°C
  • General: Jaundiced female, mild distress
  • Abdomen:
  • Soft, mildly tender RUQ
  • Surgical drain in place with bilious output
  • Laparoscopic port sites healing
  • No peritonitis
  • Skin: Icteric sclera, jaundiced skin

Laboratory Results

  • WBC: 11,400/μL
  • Total bilirubin: 8.4 mg/dL (elevated)
  • Direct bilirubin: 6.8 mg/dL
  • ALT: 186 U/L
  • AST: 142 U/L
  • Alkaline phosphatase: 348 U/L
  • GGT: 420 U/L

Drain Fluid Analysis

  • Bilirubin in drain fluid: 24 mg/dL (consistent with bile)

Imaging

CT Abdomen with IV contrast:

  • Fluid collection in gallbladder fossa
  • Dilated intrahepatic bile ducts
  • Surgical clips in porta hepatis
  • Concern for bile duct injury

MRCP (Magnetic Resonance Cholangiopancreatography):

  • Complete transection of common hepatic duct
  • Dilated intrahepatic ducts above clip level
  • Distal CBD not visualized (separate from proximal system)
  • Consistent with Strasberg Type E2 injury

Diagnosis

Major bile duct injury (Strasberg Type E2 - transection of common hepatic duct)

Multidisciplinary Discussion

  • Hepatobiliary surgery consultation
  • Interventional radiology consultation
  • Management options:
  1. Immediate surgical repair (not recommended in acute inflammation)
  2. Delayed reconstruction after inflammation resolves

Initial Management

  1. Maintain external drainage (controls bile leak)
  2. Percutaneous transhepatic cholangiography (PTC) with biliary drainage
  3. Nutrition support
  4. Allow inflammation to subside (6-8 weeks)
  5. Plan for definitive reconstruction

PTC and Drainage

  • Bilateral percutaneous transhepatic biliary drains placed
  • External drainage of bilateral hepatic ducts
  • Allows decompression and controls biliary output

Definitive Surgery (8 weeks later)

Roux-en-Y hepaticojejunostomy:

  • Exploratory laparotomy
  • Dense adhesions in RUQ
  • Proximal bile duct identified (dilated common hepatic duct)
  • Scarred distal bile duct excised
  • Roux limb (60 cm) created
  • End-to-side hepaticojejunostomy (single layer, absorbable sutures)
  • Transhepatic stents left in place

Postoperative Course

  • ICU admission for 24 hours
  • Diet advanced POD 4
  • Transhepatic drains capped, then internalized
  • Discharged POD 7

Follow-up

  • Drains removed at 6 weeks (after cholangiogram confirming patent anastomosis)
  • Liver enzymes normalized
  • No stricture at 1 year follow-up

Teaching Points

  1. Bile duct injury most common with cholecystectomy (0.3-0.5%)
  2. Risk factors: Acute inflammation, anomalous anatomy, inadequate exposure
  3. Critical view of safety (CVS) helps prevent injury
  4. Early recognition allows appropriate referral
  5. Delayed reconstruction (6-8 weeks) has better outcomes than immediate repair
  6. Hepaticojejunostomy is standard repair for major bile duct injury
  7. Long-term stricture risk requires surveillance

Clinical Image

Image Description: MRCP image demonstrating complete transection of the common hepatic duct with dilated intrahepatic bile ducts above the level of injury. The discontinuity of the biliary system confirms a major bile duct injury requiring reconstruction.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Liver_cancer

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