1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction of Case  Complication  Right hepatic duct injury  Procedure  Laparoscopic converted to open cholecystectomy, Intraoperative cholangiogram, Roux-en-Y, hepaticojejunostomy  Primary Diagnosis  Symptomatic Cholelithiasis

3. Clinical History  64 y/o male with 4 month h/o of worsening RUQ quadrant pain associated with food intake. Pt was worked up with EGD (normal), CT scan of Abd and Pelvis and u/s that showed gallstones. Pt denied any fever or chills.  PMH: Asthma, Arthritis,Hyperlipidemia, HTN, CAD  PSURG: bilateral knee surgery and back surgeries  ALL-NKDA  FH-CAD, DM  Social- smoking, social alcohol  MEDS:ASA, Statin, Atenolol Losartan

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  LABS: HBG- 13 WBC 7.0, AST-30, ALT-20, ALK-P 80, T.B-0.4, Amylase- 50, Lipase 150  RUQ Ultrasound- cholelithiasis, no evidence of acute cholecystitis, normal CB size, no intra or extra- hepatic dilation

5. OR  Started laparoscopically then converted to open due to omentum firmly attached  Subcostal incision- significant inflammatory process  Dissection was done from the top down  Cystic artery and duct was identified, and suture proximal and distal  Gallbladder removed, bile was seen in fossa that was coming from a medial structure  Bovie injury seen on right hepatic duct through-and-through injury, greater than 50%- intra-op cholangiography  Roux-en-Y, hepaticojejunostomy  5 French Silastic feeding tube inserted into the hepatic ducts  Roux limb -60 cm from the ligament of Treitz  Blake drain placed

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9. Hospital Course  Extubated POD O  Transfer out of SICU on POD2  Started clears POD5  D/C home today.

10. Analysis of Complication Was the complication potentially avoidable? - Yes, technical. 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  Cholangiography to evalaute anomalies, clarify difficult anatomy and to detect common bile duct stones  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