Laparoscopic hepaticojejunostomy after bile duct injury

Abstract

Background

The incidence of bile duct injuries (BDI) after cholecystectomy, which is a life-threatening condition that has several medical and legal implications, currently stands at about 0.6 %. The aim of this study is to describe our experience as the first center to use a laparoscopic approach for BDI repair.

Methods

A prospective study between June 2012 and September 2014 was developed. Twenty-nine consecutive patients with BDI secondary to cholecystectomy were included. Demographics, comorbidities, presenting symptoms, details of index surgery, type of lesion, preoperative and postoperative diagnostic work-up, and therapeutic interventions were registered. Videos and details of laparoscopic hepaticojejunostomy (LHJ) were recorded. Injuries were staged using Strasberg classification. A side-to-side anastomosis with Roux-en-Y reconstruction was always used. In patients with E4 and some E3 injuries, a segment 4b or 5 section was done to build a wide anastomosis. In E4 injuries, a neo-confluence was performed. Complications, mortality, and long-term evolution were recorded.

Results

Twenty-nine patients with BDI were operated. Women represented 82.7 % of the cases. The median age was 42 years (range 21–74). Injuries at or above the confluence occurred in 62 %, and primary repair at our institution was performed at 93.1 % of the cases. Eight neo-confluences were performed in all E4 injuries (27.5 %). The median operative time was 240 min (range 120–585) and bleeding 200 mL (range 50–1100). Oral intake was started in the first 48 h. Bile leak occurred in 5 cases (17.2 %). Two patients required re-intervention (6.8 %). No mortality was recorded. The maximum follow-up was 36 months (range 2–36). One patient with E4 injury developed a hepaticojejunostomy (HJ) stenosis after 15 months. This was solved with endoscopic dilatation.

Conclusions

The benefits of minimally invasive approaches in BDI seem to be feasible and safe, even when this is a complex and catastrophic scenario.

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