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home - Biliary - Miscellaneous - Cholecystectomy complications Written by Dr Sebastian Zeki

Cholecystectomy complications

Written by Dr Sebastian Zeki Leak Presentation Stent can be removed in 3-5 days Surgical mortality 5 %, restenosis 20 %. If biliary cirrhosis may need liver transplantation Type A- duct leak but no continuity lossLeakage occurs into the gallbladder bed from minor hepatic ducts/cystic duct.There is no loss in continuity of the biliary tree. Biliary Injury Classification Management:If bile leak recognised at operation, T-tube should be insertedAvoid repairing CBD as it strictures. If significant injury, hepaticojejunostomy better. Management: No leak- remove stent/ Minor leak- remove stent and sphincterotomyType D can develop into type E injury-More difficult to correct type C by ERCP as section of liver separated from natural flow 3. Port site: Can bleed 2. Cystic art: Clip cystic art if bleeding- ensure it’s not R hepatic art 1. Liver bleed: Usually from the close proximity of the middle hepatic vein and its radicals to the gallbladder fossa during gallbladder removal Type E-Injuries to common bile or common hepatic ducts This is classified according to the level of injury in the biliary tree.Jaundice can occur weeks to years after surgery.USS shows dilated intrahepatic ducts.On ERCP, the IHDs dont fill/ PTC delineates IHD and allows precutaneous hepatic duct stenting. Type DThis refers to lateral damage to the CBD.This may progress to type E injury. Type C- Duct leak injuryThis refers to the duct being transected but not occluded.It is assoc with injuries to the right hepatic artery. Type B-Occlusion injury to RHDThis refers to injuries that involve cystic duct drainage into an aberrant RHD (2 % of patients)-usually because the RHD is mistaken for the cystic duct.This causes segmental cholestasis and right lobe atrophy.This can present with cholangitis.ERCP shows absent segmental RHD .CT shows focal atrophy or cystic dilation. ManagementInsert stentRepeat HIDA/ MRCP 2-4 weeks post stent insertion Management: Need hepaticojeju-nostomy +/-segmental resection of the affected lobes if significant atrophy Management: Remove stent at 2 weeks if leak resolved at ERCP and patient is well Leak Work-up:-Gallbladder fossa drain if seen during op.-USS/ CT to identify leak.-ERCP - Type A to D leak can all be managed by insertion of 10Fr stent across ampulla ro reduce biliary pressures.Sphincterotomy without stent insertion can be used. Complications Of Cholecystectomy Complication Rates: Bleeding (1.7%), Abscess (0.2%), Bile leak (0.6 %), Biliary injury (0.4 %), Bowel injury (0.21%). Bowel InjuryPrevalence of 0.4%Usually present within 96hours post-procedure Bleeding ComplicationsOccurs from 3 sites: - the liver, arterial sources, or port insertion sites. USS only: Small perihepatic fluid collections are seen in 50% within 24 hours post-op.No clinical significance. Major biliary leakage is usually seen 2 to 10 days postcholecystectomy.Clin pres: fever, abdominal pain, and/or bilious ascites, mild jaundice,Increasing WCC.Bilirubin will be mildly elevated as the body reabsorbs Usually from damage to 1. Cystic duct remnant-Laceration of a small cystic duct/ Clip or ligature on cystic duct dislodged-Ductal necrosis from cholecystitis/ Distal CBD stone obstruction and cystic duct remnant blow out.