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Case 9: Bile in the drain post cholecystectomy

A 55 year old woman is referred to you 10 days post cholecystectomy. The procedure was performed for acute cholecystitis and the dissection was difficult. The original surgeon reported finding "aberrant anatomy". There has been persistent drainage of bile from the drain left at operation at approximately 500ml/day.

1. What type of xray is this and what does it show?

A sinugram has been performed with instillation of water soluble contrast via the drain tube. The contrast is seen to flow into a cavity that communicates with the left and right hepatic ducts.

2. How would you manage this problem?

The immediate concern is assessment and resuscitation of the patient who may have severe biliary peritonitis. If the drain has created a controlled fistula then this allows time to obtain further investigations to define the anatomy and plan definitive management.

3. How would you classify this injury?

The Strasberg classification is the most practical and widely used classification. It incorporates the Bismuth classification which was initially developed to classify hilar cholangiocarcinoma.

This injury is a Strasberg E4 or Bismuth 4 with resection of the common hepatic duct including the confluence resulting in separation of the right and left ducts.

Further reading
Complications of cholecystectomy
Bile duct injuries during laparoscopic cholecystectomy: management and outcome.
Comprehensive list of hepatobiliary references - from Surgical tutor

Powerpoint Presentations
Diagnosis and management of bile duct injury