1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction of Case  Complication  Bile Leak from Common Hepatic Duct Injury  Procedure  Laparoscopic Converted to open Cholecystectomy  Primary Diagnosis  Symptomatic Cholelithiasis

3. Clinical History  51 y/o male with 3 month h/o of worsening RUQ quadrant pain associated with fatty food. Pt denied any fever or chills. Pt was worked up with ultrasound that showed gallstones.  PMH: None  PSURG: None ( Stab in RUQ in 80’s did not require surgery)  ALL-NKDA  FH-CAD, DM  Social- smoking, social alcohol  MEDS: None

4. Clinical History  PE- 99.1 HR-70 BP-140/80 100% on RA  GEN-AAA, in no acute distress  RESP-CTA B  CV-RRR  ABD-s/nt/nd, BS, 4 cm scar in RUQ, no hernia  LABS: HBG- 17 WBC 7.0, AST-30, ALT-31, ALK-P 80, T.B-0.4, Amylase- 50, Lipase 70  RUQ Ultrasound- cholelithiasis, no evidence of acute cholecystitis, normal CB size, no intra or extra- hepatic dilation

5. OR  Started laparoscopically  Adhesions were then taken down gently with electrocautery  Abberent Duct anatomy; thought there was duplicated cystic duct  Dissecting 30-45 minutes  Converted to open cholecystectomy  Other duct structure was most likely low right hepatic duct or branch  Left Jp- drain in gallbladder fossa

6. Hospital Course  Pt continue to have 200cc of Bile from JP drain  Worked up with Ultrasound and MRCP  MRCP-no injury or stone in CBD  (2/22) 2 weeks Post op Clinic- pt with <200cc day  Pt presented To ER with RUQ pain, GI- consult for ERCP, HIDA  HIDA scan-Radiotracer visualization in the patient's anterior abdominal drain consistent with bile leak  ERCP-Small biliary leak from the proximal common hepatic duct  Right biliary ductal anomalous anatomy  Biliary and pancreatic duct stents left in place.

9. Hospital Course  Post ERCP pt increase JP output >600cc  Pt presented to ER with worsen RUQ pain  To OR for Ex.Lap, Roux-en-Y hepaticojejunostomy, and Intra-op cholangiogram  Intraoperative cholangiogram was performed which revealed patent left and right ductal systems and the defect in the common hepatic duct

10. Analysis of Complication Was the complication potentially avoidable? - Yes, technical and delay in diagnosis Would avoiding the complication change the outcome for the patient? – Yes, increase risk of morbidity/ mortality What factors contributed the complication? – Technical

11. Teaching Points  Clearly identify the cystic duct at its junction with the gallbladder  Limit the use of all energy sources near the Common Bile Duct and recognize that they can cause occult injury  Don’t hesitate to convert to an open operation for technical difficulties, anatomic uncertainties, or anatomic anomalies  Bile duct injuries with laparoscopic cholecystectomy (0.5 to 2.7%)  The standard operation for reconstruction of a major bile duct injury after laparoscopic cholecystectomy is a Roux-en-Y hepaticojejunostomy  20% of the population has accessory hepatic ducts  In these individuals, the aberrant duct joins the common hepatic duct at various locations along its course

12. Variation  Normal and variant biliary ducts. A, Normal biliary tree. B, Trifurcation of biliary duct (arrow). C, Right dorsocaudal branch (arrow) draining into left hepatic duct. D, Aberrant right hepatic duct (arrow) emptying into common hepatic duct. E, Aberrant right hepatic duct (arrow) draining into cystic duct

13. Variation