The image shows numerous clips at the site of surgery. There appears to be
a hole just beside the clips seen to the left of the image which are
presumably on the cystic duct. There appears to be mucosa and granulation
tissue in the edges of the hole and bile is seen to be coming from the hole.
Thats a difficult question, these images are much easier to interpret at
the actual laparoscopy. It looks like we are at the site of the previous
surgery because I can see multiple clips. The two clips to the left are
probably on the cystic duct and the clip in the lower right part of the image
could be on the cystic artery. The hole appears to be medial to the two clips
on the cystic duct so perhaps the hole is in the cystic duct or indeed is in
the common bile duct.
Management of someone with a bile leak post cholecystectomy depends on
several things. Foremost the clinician must recognise that there is a problem.
The patient slowly deteriorates so recognition may be delayed. Another
contributing factor is the so called Ostrich behaviour of the
clinician, who blinds him/her self to the fact that there is a problem, in the
hope that if he/she does not recognise it, the problem will not exist. The
clinician must consider the possibility of a bile leak in any patient post
cholecystectomy whose recovery is slow.
Either an ultrasound scan or a CT will confirm the suspicion. Then the
acute problem with respect to the large volume of fluid that has accumulated
must be addressed, this is best managed by placement of a drain. Placement of
the drain is best accomplished in the radiological department following the
scan.
The next priority is treating any sepsis. Further treatment depends on the
cause of the leak and whether or not there is a distal obstruction. If there
is a leak from the gallbladder bed or the cystic duct stump, with no distal
obstruction then no special additional treatment is required. Indeed further
intervention may be hazardous to the patient. If the leak is from the cystic
duct stump or gallbladder bed and there is a distal obstruction, it may be
possible to remove a common stone and place an internal drain at ERCP. The
ERCP also offers the opportunity to visualise the biliary anatomy. If the leak
is from a transected bile duct then the patient should be treated with the
external drain to develop a bilio-cutaneous fistula, when any sepsis has
settled then reconstruction of the biliary system is best accomplished by a
hepatico-jejeunostomy performed in an experienced hepato-biliary unit.
The rate of bile duct injury following open cholecystectomy is about 0.3%
(1 in 333), following laparoscopic cholecystectomy, the rate is higher in the
order of 0.5% (1 in 200).
