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Arch Surg. 2010;145(11):1124. doi:10.1001/archsurg.2010.236-b.
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ANSWER: TRANSECTED RIGHT POSTERIOR HEPATIC DUCT

Injuries to the biliary tree are associated with both laparoscopic and open cholecystectomy. The laparoscopic approach has rapidly replaced the conventional open cholecystectomy, which has reduced hospitalization times and enabled a faster return to normal activities. However, there is a higher incidence of bile duct injuries during laparoscopic cholecystectomy compared with open, and misidentification of the ductal anatomy appears to be the most common cause of iatrogenic postoperative bile leaks.1An important anatomic variant is the low insertion of a right segmental hepatic duct, which places it in a position at risk to be injured during laparoscopic cholecystectomy.2The ERCP may miss the injury in the presence of biliary anatomic variants such as the low-inserting right segmental hepatic duct, and this study will demonstrate the presence of a hepatic bifurcation with ductal branches in both the right and left lobes of the liver.2However, on further examination, there is an absence of complete filling of the right biliary ductal system.

In this case, findings of ERCP were described as normal, though the right posterior duct had been injured. On readmission to the hospital, owing to the patient's persistent bile drainage, a percutaneous transhepatic cholangiogram (PTC) was performed. The PTC revealed an isolated right posterior ductal system that was dilated, with no communication with the common bile duct (Figure 3). One month later, the patient was taken to the operating room to undergo repair of her bile duct injury. She underwent a Roux-en-Y hepaticojejunostomy from the jejunum to the intrahepatic right posterior duct.

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Figure 3.

Percutaneous transhepatic cholangiogram filling right posterior hepatic duct.

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When there is a suspicion of a bile duct injury following normal findings on ERCP, a PTC is useful to illustrate the presence of an injury.3Another important function of the PTC catheter is its use as an aid in surgical reconstruction.4By placing the biliary catheter through the transected duct into the subhepatic space preoperatively, identification of the injured duct is facilitated and surgical repair can then be performed to the isolated duct via a Roux-en-Y hepaticojejunostomy. Bile leaks, though relatively uncommon, occur following cholecystectomy, making knowledge of biliary anatomy key to management of postoperative complications. Diagnosis of bile leaks is typically via ERCP.5Though findings of ERCP may initially appear normal, subtleties such as dilatation of the bile duct proximal to the site of leak and lack of complete filling of the ducts distal to the site of injury may be present.

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Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgeryhas temporarily discontinued accepting submissions for this feature. Requests for submissions will resume in January 2011. Thank you.

Correspondence:David A. Geller, MD, University of Pittsburgh Medical Center Liver Cancer Center, 3471 Fifth Ave, Kaufmann Medical Bldg, Ste 300, Pittsburgh, PA 15213 (gellerda@upmc.edu).

Accepted for Publication:August 17, 2009.

Author Contributions:Study concept and design: Magge, Tsung, and Geller. Acquisition of data: Magge, Tsung, and Geller. Analysis and interpretation of data: Magge, Tsung, and Geller. Drafting of the manuscript: Magge and Tsung. Critical revision of the manuscript for important intellectual content: Magge, Tsung, and Geller. Administrative, technical, and material support: Magge. Study supervision: Tsung and Geller.

Financial Disclosure:None reported.

Lillemoe  KDPetrofski  JAChoti  MAVenbrux  ACCameron  JL Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge. J Gastrointest Surg 2000;4 (2) 168- 177
PubMed
Schipper  IBRauws  EAGouma  DJObertop  H Diagnosis of right hepatic duct injury after cholecystectomy: the use of cholangiography through percutaneous drainage catheters. Gastrointest Endosc 1996;44 (3) 350- 354
PubMed
Chapman  WCAbecassis  MJarnagin  WMulvihill  SStrasberg  SM Bile duct injuries 12 years after the introduction of laparoscopic cholecystectomy. J Gastrointest Surg 2003;7 (3) 412- 416
PubMed
Hwang  SLee  SGLee  YJHa  TYKo  GYSong  GW Delayed-onset isolated injury of the right posterior segment duct after laparoscopic cholecystectomy: a report of hepatic segmental atrophy induction. Surg Laparosc Endosc Percutan Tech 2007;17 (3) 203- 205
PubMed
Strasberg  SMEagon  CJDrebin  JA The “hidden cystic duct” syndrome and the infundibular technique of laparoscopic cholecystectomy: the danger of the false infundibulum. J Am Coll Surg 2000;191 (6) 661- 667
PubMed

Figures

Place holder to copy figure label and caption
Figure 3.

Percutaneous transhepatic cholangiogram filling right posterior hepatic duct.

Graphic Jump Location

Tables

References

Lillemoe  KDPetrofski  JAChoti  MAVenbrux  ACCameron  JL Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge. J Gastrointest Surg 2000;4 (2) 168- 177
PubMed
Schipper  IBRauws  EAGouma  DJObertop  H Diagnosis of right hepatic duct injury after cholecystectomy: the use of cholangiography through percutaneous drainage catheters. Gastrointest Endosc 1996;44 (3) 350- 354
PubMed
Chapman  WCAbecassis  MJarnagin  WMulvihill  SStrasberg  SM Bile duct injuries 12 years after the introduction of laparoscopic cholecystectomy. J Gastrointest Surg 2003;7 (3) 412- 416
PubMed
Hwang  SLee  SGLee  YJHa  TYKo  GYSong  GW Delayed-onset isolated injury of the right posterior segment duct after laparoscopic cholecystectomy: a report of hepatic segmental atrophy induction. Surg Laparosc Endosc Percutan Tech 2007;17 (3) 203- 205
PubMed
Strasberg  SMEagon  CJDrebin  JA The “hidden cystic duct” syndrome and the infundibular technique of laparoscopic cholecystectomy: the danger of the false infundibulum. J Am Coll Surg 2000;191 (6) 661- 667
PubMed

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