Omentoplasty Combined With Endoscopic Stenting in the Treatment of Lateral Duct Injury at Hepatic Duct Bifurcation.

BACKGROUND

Common bile duct injury (CBDI) is a devastating complication from laparoscopic cholecystectomy. The endoscopic retrograde cholangiopancreatography (ERCP)-based sphincterotomy and stenting were reportedly effective in treating low or distal lateral CBDI. However, in the circumstance of proximal lateral CBDI, the routine biliary stent may not provide coverage of the leak site, which posed a unique clinical challenge when such proximal CBDI occurred.

METHODS

This patient is an 85-year-old man who underwent laparoscopic cholecystectomy for acute cholecystitis. The gallbladder was contracted and atrophic with extensive dense adhesions in the infundibular area. A dome-down approach was attempted, and a small side hole was identified from a tubular structure with minimal bilious leakage. The intraoperative cholangiogram showed a bile leak at the hepatic duct confluence. A vascularized omental patch was fashioned and secured to the vicinity of the CBDI in a tension-free manner. Two drains were placed. ERCP and endoscopic stenting were undertaken the following day.

RESULTS

There was minimal bilious fluid output from the Jackson-Pratt drains in the first 24 hours. This was reduced further following ERCP and resolved in 2 days while tolerating a regular diet. All laboratory studies were normal. The drains were removed week postoperatively. The patient was seen in the clinic at 12 months, and there was no evidence of bile leak or stricture.

CONCLUSION

The combination of omentopexy and endoscopic stenting is safe in managing high lateral bile duct injury. Prospective studies are needed to further validate this technique.