Post-cholecystectomy acute injury: What can go wrong?

Backgrounds/aims: Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries.

Methods: We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management.

Results: Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy.

Conclusions: Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.