On 7th postoperative day after laparoscopic cholecystectomy, pt. developed . upper abdominal pain and 10 cm X 8 cm collection. Treatment consists of -
Ans (b) Percutaneous drainage "Subhepatic abscesses or localized biliary collections require prompt drainage." - Textbook of Liver & Biliary Surgery Post Cholecystectomy bile leak It occurs due to slipping of ligature from the cystic duct or bile duct injuries which go unrecognized at the time of surgery. Bile leakage presents themselves in the postoperative period by pain and fever, with or without abnormal liver function tests and jaundice. Other manifestations include external discharge of bile through the drain or surgical incision or biliary peritonitis or biloma or cholangitis. Initial investigation of these patients includes U/S or CT (preferably CT) for detection of any fluid collection. Any biliary collection or subhepatic abscess should be promptly drained. Minor collection, after percutaneous drainage, needs no fuher treatment, if the patient improves. However, in the presence of any major leak, jaundice, signs of cholangitis, the patient should be investigated with an ERC (or PTC) to establish the presence, extent and severity of bile duct injury. Management of Cystic duct bile leaks are usually due to slipping of ligature or clip. can be managed by endoscopic sphincterotomy and stenting (the principle behind is that if the bile is allowed to flow through the normal tract, any fistulous communication would heal spontaneously) The above mentioned management of cystic duct leak is given in Sabiston; Blumga's Surgery of the liver and biliary tract; Textbook of Liver & biliary, surgery by William C Meyer and in Maingot's abdominal operations. But Maingot adds ? "However in patients who develop this complication after laproscopic surgery, the author ours relaparoscopy with suction of extravasated bile and ligature of the cystic duct stump by a catgut endoloop. A laproscopic approach appears to be more direct and definitive and avoids the risk, albeit small of endoscopic sphincterotomy and stenting." Management of bile duct injuries the basic approach is biliary decompression, either by endoscopic sphincterotomy & stenting or by transhepatic catheters Some fistulas may close spontaneously by biliary decompression - For the major injuries (like complete transection of CBD or hepatic ducts) not responding, definitive repair is done. But definitive repair is delayed 6 to 8 weeks until acute inflammation has resolved. Definitive repair includes - Roux-en-V choledochojejunostomy or - hepaticojejunostomy All patients with biliary leak should be well nourished and kept free of infection. Also know the management, if bile duct injury is recognized at the time of cholecystectomy. Management of the Bile Duct Injury Recognized at the Time of Cholecystectomy A small, non-cautery-based paial lateral bile duct injury 4 can be managed with placement of a T tube. If the biliary injury is more extensive, or if there is significant thermal damage owing to cautery-based trauma, or if the injury involves more than 50% of the circumference of the bile duct wall 4 an end-to-side choledochojejunostomy with a Roux-en-Y loop of jejunum should be performed. Injury to isolated hepatic ducts smaller than 3 mm or those draining a single hepatic segment 4 can be safely ligated.
Immediate laparotomy
Percutaneous drainage
Laparotomy & surgical exploration of bile duct and T tube inseion
All