Bile leak, jaundice, and gallbladder fossa fluid are relatively common complications after cholecystectomy, and they are more dangerous, with bile leak being the most common. From October 2005 to October 2008, 453 cholecystectomies were performed in our department, among which 3 patients had biliary leakage, 1 patient had jaundice, 1 case of gallbladder fossa effusion, and 1 case of abdominal abscess treated by secondary surgery. The causes, management and lessons learned are analyzed and discussed as follows.
Among the 453 patients in this group, 164 were male and 289 were female, aged 16-83 years, with an average age of 54.2 years. Among them, 6 patients had complications for secondary surgery, including 1 male and 5 female, aged 47-65 years, with an average of 56 years. There were 3 cases of bile leak, with an incidence of 0.66%; 1 case of jaundice, with an incidence of 0.22%; 1 case of gallbladder fossa effusion and 1 case of abdominal abscess, with an incidence of 0.44%. Causes of bile leak: 1 case of bile cystic duct stump leak, 1 case of common bile duct injury, and 1 case of leak after T-tube extraction. Causes of jaundice: partial entrapment of the right hepatic duct. Causes of gallbladder fossa effusion and abdominal abscess: severe acute edema and incomplete postoperative drainage.
Bile leak
Bile leak is mostly seen after cholecystectomy and should be given great attention because the injury, especially after transection of the common bile duct, often brings catastrophic consequences to the patient, and many patients may suffer lifelong disability or even death as a result. Once it occurs, the most appropriate treatment should be done according to the pathological type of the injury. Strictly grasp the timing of surgery, surgical indications and surgical methods, and now the various cases are summarized and analyzed as follows.
Common hepatic duct transection injury
One case of transverse injury to the common hepatic duct occurred during LC surgery in this group. A rubber drain was placed in the gallbladder fossa during surgery, and on the day after surgery, bile-like fluid flowed out of the drainage tube about 450 ml. The patient recovered well. Our experience is that the long term result is better for the damaged common hepatic duct with Roux-en-Y hepatic duct-jejunum anastomosis, and for the bile leak caused by bile duct injury, early secondary surgical exploration and hepatic-enteric anastomosis should be performed.
Leakage of bile duct stump
In this group, there was one case of bile leak from the stump of the cystic duct, which was found to be a thick cystic duct after LC surgery, and two titanium clips were placed on the stump of the cystic duct, after which the patient showed symptoms of peritonitis, jaundice and liver function impairment, and bile-like fluid was extracted by laparotomy. The patient recovered well. Therefore, the titanium clip for the stump of the cystic duct is not more but more precise, and of course, if the cystic duct is found to be thicker, Reoder loop ligation can be used.
Bile leak due to unformed sinus tract around T-tube
In this group, there was one case of bile leak caused by unformed sinus tract around T-tube, the patient was combined with diabetes mellitus, and the symptoms of peritonitis appeared after removal of T-tube 21 days after surgery, and bile fluid was extracted by abdominal puncture. Our experience is that the extraction time should be delayed appropriately for elderly patients and patients with combined diabetes mellitus and other diseases.
Jaundice
Jaundice is one of the common complications after LC, and its impact on the body is multifaceted. Timely analysis of the causes and proper management are the keys to prevent the occurrence of adverse prognosis.
In the present case, the patient developed jaundice after LC surgery and progressively worsened, and liver function tests indicated a significant increase in direct bilirubin, which was considered to be obstructive jaundice.
Therefore, the occurrence of jaundice after biliary surgery may be related to both improper surgical operation and completely unrelated to surgery. For jaundice that has recently appeared after cholecystectomy, one should make a correct judgment in a timely manner, and the other should be treated properly. The identification of the etiology of postoperative jaundice is extremely critical. A high sense of responsibility and good psychological quality are required, and cholecystectomy should never be taken lightly as a general minor surgery;
It is important to have solid basic knowledge and abundant surgical skills, and to strictly master the indications for surgery: good anesthesia and adequate exposure are also extremely important. It is important to be familiar with the normal anatomy and variant relationships of the hepatobiliary system. In particular, all ducts in the triangle of the gallbladder. They should not be clamped, ligated or cut off at will before their nature is clarified, and they should not be blindly sutured on the near bile duct side. During surgery, the gallbladder triangle is first dissected to reveal the gallbladder artery, which is ligated and severed close to the wall of the gallbladder, and then the cystic duct is treated.
Effusion in the gallbladder fossa and abdominal fluid
In this group, there were one case of gallbladder fossa effusion and one case of abdominal cavity abscess, both of which were post-operative LC patients, and all of them had acute onset and were operated on urgently. The patient recovered well after the second surgical drainage and had a good follow-up.
The reason was more exudation and vagal bile duct leakage from the liver bed in the acute phase. Therefore, patients in the acute edema phase should be adequately drained intraoperatively to prevent the accumulation of inflammatory exudate causing discomfort, prolong the placement of drains and place silicone tubes with thick inner diameter and many lateral holes intraoperatively.
In conclusion, medically induced injuries during cholecystectomy can be avoided. First, the operator is required to have a high degree of responsibility, pay attention to the standardization of gallbladder surgery operation, and flexibly use the paralleolar and retrograde resection methods. Avoid arbitrary sharp separation for tissues with unclear anatomical levels, especially in patients with recent reoperation. Second, good anesthesia and adequate incisional exposure make the surgical field clear, which can avoid excessive traction or injury from inconvenient operation.
Third, skilled anatomical knowledge and careful execution of each surgical step are required. “See and recognize, do not pull, rather complicated than simple”. Fourth, strictly grasp the timing of surgery, make adequate preoperative preparation and emergency measures. In particular, the timing of the second surgery after injury selection and preparation, must not be rushed, otherwise it will be more harmful.