Successful management of iatrogenic bile duct injury by laparoscopic ligation

Abstract

Background: Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures in the western world. Despite increased experience and improved training the incidence of major bile duct injury remains between 0.5% and 1%. Conventional surgical teaching dictates that all transections of the major bile ducts should be managed with a Roux-en-Y reconstruction. Case outline: A transection injury of the right hepatic duct was managed by laparoscopic ligation in a 45-year-old woman. At 6-month follow-up the patient remained well with normal liver enzymes. A CT scan demonstrated an essentially normal liver with only minimal dilatation of the right hepatic duct just proximal to the surgical clips. The absence of any right-sided liver atrophy suggests a communication between the right and left hemi-livers that was not detected by either cholangiogram or ERCP. Discussion: Laparoscopic ligation of transected right and left hepatic ducts spares the patient not only a laparotomy but also the potential lifelong complications of a Roux-en-Y reconstruction. Although simple duct ligation has not been reported previously as a management strategy for isolated hepatic duct transection, it is likely that patients who have had their right hepatic ducts ligated inadvertently at laparoscopic cholecystectomy have displayed no postoperative complications and therefore never come to the attention of the surgical team. This technique of laparoscopic ligation of transected hepatic ducts may well have a place among the therapeutic options under consideration when managing these iatrogenic injuries.