Cyst of the Canal of Nuck in a Two Year Old Girl

CASE REPORT doi: 10.5455/medarh.2014.68.291-293

Med Arh. 2014 Aug; 68(4): 291-293

Received: May 25th 2014 | Accepted: June 09th 2014
© AVICENA 2014

Iatrogenic Injury to the Common Bile Duct

Sead Buturovic
Department of Surgery, General hospital Konjic, Konjic, Bosnia and Herzegovina

Corresponding author: prof. Sead Buturovic, MD, PhD. Department of Surgery, General hospital Konjic, Konjic, Bosnia and Herzegovina.
E-mail: sean@[Link]

ABSTRACT
Introduction: The formation of gallstones in the gall bladder is very common. It is now considered that approximately 10% to 15% of the
adult population has gallstones. It is more frequent in women than men. Etiologies are various and include: age, sex, diet, sudden weight
loss, etc. According to the report of the US National Institute of Health, it is estimated that 6.3 million men and 14.2 million women, aged
20-74 years in the United States has calculosis of the gallbladder, due to which every year is performed about 700,000 cholecystectomy.
Case report: Male patient, aged about 40 years, admitted at the Clinic and laparoscopic surgery was performed in our department for
chronic, as multiple, symptomatic gallbladder calculi. Intraoperative findings showed chronically inflamed, curled gall bladder, and wall
thickening. After the first postoperative day there is no content in the drain bag and it is taken out, and the patient leaves the hospital
without any problems. The seventh post-operative day occurred abdominal pain, weakness and fatigue, with striking yellow skin and
visible mucous membranes. Clinical, laboratory and echo determined abdomen full of fluids, so it was suspected lesion of the bile duct.
Urgent revision was performed. Intraoperative was found a lesion of the common bile duct in the form of a complete interruption. Cre-
ated is anastomosis through transhepatic drain according to Pradera. Early and late postoperative flow was entirely normal with normal
laboratory and echofindings. Control, contrast imaging through a drain showed the orderly flow of extrahepatic bile ducts, with minimal
extravasation of contrast. Conclusion: At the Department of Surgery of General Hospital in Konjic laparoscopic cholecystectomy is per-
formed since 1999. In the beginning it was done by three trocars (European style), and later, in order to prevent complications or injury
of the bile duct is performed surgery with four trocars (American style). The number of complicated procedures in our hospital does not
differ from similar indicators in foreign surgical facilities.
Key words: common bile duct injury, laparoscopic cholecystectomy, complications.

1. INTRODUCTION diagnostic tests which prove the existence of stones or

The formation of gallstones in the gall bladder is very changes in the gall bladder.
common (1-6). It is now considered that approximately Routine diagnostics include: a) clinical history; b) clini-
10% to 15% of the adult population has gallstones. It is cal examination; c) complete laboratory tests; d) X-ray of
more frequent in women than men. Etiologies are various the lungs and heart; and e) echo examination. Additional
and include: age, sex, diet, sudden weight loss, etc. diagnostic methods are CT and ERCP.
Gallstones do not have to cause any problems and then According to the report of the US National Institute
they are called asymptomatic. But they can cause symp- of Health, it is estimated that 6.3 million men and 14.2
toms such as pain below the right rib cage. The pain is million women, aged 20-74 years in the United States has
accompanied by nausea or vomiting. Sometimes the pain calculosis of the gallbladder, due to which every year is
spreads to the back and can last from several minutes to performed about 700,000 cholecystectomy (1).
several hours, it usually occurs after meals, especially af- In patients with symptomatic gallstones treatment is
ter heavier and fatty foods. removal of the gallbladder with stones in it. The surgery
In patients with problems, or symptoms due to gall- for removal of the gallbladder is called a cholecystectomy.
stones, surgical treatment is necessary, because in 3% of It could be an urgent or planned. Surgical removal of the
these patients within a year occurs some form of compli- gallbladder is not performed because it “contains stones,
cation. The most common complications are: a) acute in- but because it creates stones”. In today’s world and in our
flammation of the gallbladder, when stone is stuck on the county the method of choice for removal of the gallblad-
exit from the gall bladder and requires urgent surgery; b) der is considered laparoscopic cholecystectomy, which
choledocholithiasis (stones from the gallbladder bile en- represents the “gold standard”.
tering the conduits, which can be clogged); c) cholangitis
(purulent bile ducts); d) an acute inflammation of the pan- 2. CASE REPORT
creas; e) bowel obstruction by calculus (if the stone passes Male patient, aged about 40 years, admitted at the Clin-
into the duodenum or small intestine); f ) carcinoma of ic and laparoscopic surgery was performed in our de-
the gallbladder. The existence of the symptoms requiring partment for chronic, as multiple, symptomatic gallblad-

Med Arh. 2014 Aug; 68(4): 291-293 291

Cyst of the Canal of Nuck in a Two Year Old Girl

Figure 1a, b, c. Laparoscopic cholecystectomy: surgical treatment

der calculi. Intraoperative findings showed chronically so in that case it is performed a conversion (traditional
inflamed, curled gall bladder, and wall thickening. After surgery).
the first postoperative day there is no content in the drain National Institutes of Health of the United States passed
bag and it is taken out, and the patient leaves the hospital in the 1992 conclusion that laparoscopic cholecystectomy
without any problems. The seventh post-operative day oc- is the treatment of choice for symptomatic cholelithiasis.
curred abdominal pain, weakness and fatigue, with strik- The first country in South Eastern Europe which has ac-
ing yellow skin and visible mucous membranes. Clinical, cepted this conclusion was Croatia (1997).
laboratory and echo determined abdomen full of fluids, After open gallbladder surgery the patient returns to
so it was suspected lesion of the bile duct. Urgent revision work after 4 to 6 weeks. After laparoscopic surgery, the
was performed. Intraoperative was found a lesion of the patient leaves the hospital the same day, or the day after,
common bile duct in the form of a complete interruption. and may begin with everyday activities after 6-7 days.
Created is anastomosis through transhepatic drain ac- Also, due to minor trauma of the organism is reduced bi-
cording to Pradera. Early and late postoperative flow was ological metabolic response. Hypercoagulability of blood
entirely normal with normal laboratory and echofindings. is lower due to less stress, which contributes to minimal
Control, contrast imaging through a drain showed the or- danger of deep vein thrombosis and pulmonary embo-
derly flow of extrahepatic bile ducts, with minimal extrav- lism. It was shown that laparoscopic cholecystectomy has
asation of contrast. significantly fewer complications than the open, but the
Figure 1 an 2 show operative reconstruction of iatro- iatrogenic lesions of the biliary tract occur twice or even
genic lesions of the common bile duct. The patient was three times more often. Already the first major multi-cen-
monitored by surgical control findings for a longer period ter study from Europe and the United States has found
of time. All clinical and paraclinical findings was com- such injuries in 0.5% of patients. The number of biliary
pletely normal. tract injury during open cholecystectomy according to
various authors is up to 0.2%.
Injury of Luschkin duct is found in 33% of the patients
and it is a frequent complication. The biliary duct injury
can be caused by lack of surgeon experience performing
laparoscopy, but the cause may be difficult operating find-
ings, such as gangrenous, acutely inflamed or atrophic
gallbladder, which is a consequence of long-term chronic
inflammation. Sometimes it is difficult to understand the
anatomically changed relationships and erroneous sur-
gical evaluation results in this complication. A common
injury of the anatomical relations is the connection of
the cystic duct into the right hepatic duct. Mirizzi syn-
drome is a wide communication between infudibulum of
the gallbladder and hepatic duct, so the surgeon can cut
away part of hepatic duct thinking that it belongs to the
Figure 2. Postoperative RTG control examination gallbladder.
Cala and colleagues describe two types for classification
3. DISCUSSION of biliary tract injuries during laparoscopy: a) Way clas-
As father of laparoscopic cholecystectomy is consid- sification and b) Bismuth classification. According to the
ered a French surgeon Mouret, who in 1987 by laparo- type and severity of biliary tract injuries were divided into
scopic method tourniquet artery and of the cystic duct, 5 groups (Way classification):
and removed gallbladder removed by mini laparatomy, •• Puncture or minor lateral cutting injuries to the
but he did not publish his results (1). After him, this was duct;
performed by the French doctors Dubois and Perissat in •• Setting clips on the right or left hepatic duct, com-
1988. McKennan and Saye, the same year, performed the mon hepatic duct or choledocus, but without cut-
first laparoscopic cholecystectomy in the United States. In ting;
2-4% of patients, this surgery cannot be fully performed, •• Full cut of the common hepatic duct or choledocus;

292 Med Arh. 2014 Aug; 68(4): 291-293

 Cyst of the Canal of Nuck in a Two Year Old Girl

•• Completely cut of the right or left hepatic duct; jejunal curve according to Roux, termino-lateral, by re-
•• Strictures. sorbable suture 5/0. Seams are single, and by making up
•• With regard to the place of stricture Bismuth and nodes outside the lumen.
Blumgart divided them into four groups: As the choice of therapy should be considered also en-
•• Stricture affect more than 2 cm from the confluence; doscopic choledocus drainage, setting prosthetics trough
•• Stricture affect less than 2 cm from the confluence; the papilla Vateri and papillotomy.
•• Stricture at the confluence; Prevention of biliary tract injuries, and thus the occur-
•• Strictures on the left or right gall duct. rence of enteric fistulas and recurrent cholangitis allow
In case of stab wounds or minor cuts symptoms occur intraoperative cholangiography. It is important to identify
after 2 to 4 postoperative days. The consequence is the and classify injury to the biliary tract and make quality
subhepatic collection of bile and regional and later diffuse primary care for each following reconstruction attempt
peritonitis. Patients complain on pain under the right rib more difficult and demanding.
arc in the right shoulder, body temperature is elevated,
expressed leukocytosis, hyperbilirubinemia, increased se- 4. CONCLUSION
cretion of bile into the drain, 200-400 ml/24h. If emergen- At the Department of Surgery of General Hospital in
cy surgery is not performed patients may die. Konjic laparoscopic cholecystectomy is performed since
That kind of injury can be solved by single resorbable 1999. In the beginning it was done by three trocars (Eu-
sutures at the bile duct and/or by placing the T-drain. Ear- ropean style), and later, in order to prevent complications
ly strictures and mistakenly placed clips on choledocus or injury of the bile duct is performed surgery with four
are reflected by strong biliary colic and progressive jaun- trocars (American style). The number of complicated
dice. The clips cause necrosis and wall ischemia, leading procedures in our hospital does not differ from similar
to scarring. Injuries caused by placing clips on choledo- indicators in foreign surgical facilities.
cus will be resolved by repeated laparoscopy, with special
emphasis on the vitality of the tissues to prevent stricture. CONFLICT OF INTEREST: NONE DECLARED.
Late strictures occur over weeks or months after surgery
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