Bile leak risk after laparoscopic cholecystectomyBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6922.199a (Published 15 January 1994) Cite this as: BMJ 1994;308:199
EDITOR, - I was interested in the account of laparoscopic cholecystectomy by R C G Russell.1 Complications of retained intraperitoneal calculi and biliary leak seem to be more common after laparoscopic than open cholecystectomy.2,3
A 40 year old woman who suffered from biliary colic in July 1992 was found to have a gall bladder full of stones. She was admitted for laparoscopic cholecystectomy in September 1993. At operation the gall bladder was packed with calculi and difficult to grasp. A small cystic duct was clipped and the gall bladder removed with difficulty; a few stones were left in the abdomen. The patient was discharged after 48 hours.
Four days later she was readmitted with abdominal pain, distension, and vomiting. Plain radiography showed generalised ileus. Ultrasound examination showed bilomas in the subhepatic region and pelvis mimicking stones in the urinary bladder (figure). She had a polymorphonuclear leucocytosis with a white cell count of 16000/1 and a low serum potassium concentration but otherwise normal biochemical variables.
She was treated conservatively and responded well, only to deteriorate again after five days of admission. A repeat scan showed increased intraperitoneal fluid. At emergency laparotomy over 4 litres of bile was drained and stones were removed from the subhepatic region and pelvis. The gall bladder bed was found to be sealed off by omentum. The cystic artery and cystic duct clips were intact, so most of the leak probably occurred from the gall bladder bed. The postoperative period was uneventful, and the patient was discharged after 10 days.
Biliary tract complications of laparoscopic cholecystectomy tend to occur two to eight days afterwards, common symptoms being abdominal pain, vomiting, and distension. Most bile leaks are restricted to the gall bladder bed and perihepatic region; retained calculi may or may not be present. Laparascopic cholecystectomy shortens the hospital stay, and patients can return to normal activity within a few days. When a leak is suspected radiological input is helpful to plan for appropriate treatment.
I thank Mr D J Campbell, consultant surgeon, for permission to report this case.