Heterogeneity of subvesical ducts or the ducts of Luschka: a study using drip-infusion cholangiography-computed tomography in patients and cadaver specimens

Identification and management of subvesical bile duct leakage after laparoscopic cholecystectomy: A systematic review

Bile leak is a rare complication after Laparoscopic Cholecystectomy. Subvesical bile duct (SVBD) injury is the second cause of minor bile leak, following the unsuccessful clipping of the cystic duct stump. The aim of this study is to pool available data on this type of biliary tree anatomical variation to summarize incidence of injury, methods used to diagnose and treat SVBD leaks after LC. Articles published between 1985 and 2021 describing SVBD evidence in patients operated on LC for gallstone disease, were included. Data were divided into two groups based on the intra or post-operative evidence of bile leak from SVBD after surgery. This systematic report includes 68 articles for a total of 231 patients. A total of 195 patients with symptomatic postoperative bile leak are included in Group 1, while Group 2 includes 36 patients describing SVBD visualized and managed during LC. Outcomes of interest were diagnosis, clinical presentation, treatment, and outcomes. The management of minor bile leak is controversial. In most of cases diagnosed postoperatevely, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is the best way to treat this complication. Surgery should be considered when endoscopic or radiological approaches are not resolutive.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

PURPOSE

The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies.

METHODS

A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series.

RESULTS

Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured.

CONCLUSION

Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Ducts of Luschka as a rare cause of postoperative biloma. MRCP findings

Laparoscopic cholecystectomy can be complicated by a post- operative biloma. Bile leak from the duct of Luschka is reported to be the second most frequent cause, reported in 0.15%-2% of the patients. This case report aims to underline the significance of this anatomic variation and how the management of the aforementioned complication can be facilitated by MRI- MRCP. A 78 year old male patient underwent an elective laparoscopic cholecystectomy and was found to have a post-operative biloma. An MRCP was carried out to visualize the bile tree and bile leak was identified to be originated from a duct of Luschka. The patient was referred for an ERCP, sphingterotomy and placement of biliary stent to release the pressure in the bile ducts. In the next few days the bile leak was controlled and eventually ceased. The patient was discharged free of symptoms and no sign of bile leak was to be found on his follow up imaging. In comparison with other imaging modalities picturing the bile tree, MRCP fits the ideal profile to be used as a first line choice for clinicians, as it offers detailed anatomical images with high contrast between bile and adjacent tissues, without using any contrast agent or radiation.

Two Cases of Subvesical Bile Duct Injury Detected and Repaired Simultaneously during Laparoscopic Cholecystectomy

Introduction

Subvesical bile duct (SVBD) injury is a secondary major cause of minor bile duct injury after laparoscopic cholecystectomy (LC). However, this injury is usually not recognized intraoperatively, but postoperatively.

Case Report

Case 1: the patient was an 84-year-old female, preoperatively diagnosed with acute cholecystitis. During LC, a tiny hole in the gallbladder fossa from which bile juice oozing was confirmed. Suturing was performed laparoscopically. Case 2: the patient was an 81-year-old male, preoperatively diagnosed with cholelithiasis. Because of a previous history of gastrectomy, laparoscopic adhesiolysis around the gallbladder was performed. During dissection, a small amount of bile was oozing from the surface of the liver adjacent to the gallbladder fossa. Suturing was performed laparoscopically.

Conclusion

If a small amount of bile juice was detected, meticulous observation not only around the cystic duct stump but also the gallbladder fossa should be performed. Simultaneous laparoscopic suturing was feasible, and an ideal procedure against SVBD injury developed during LC.

Efficiency of fluorescent cholangiography during laparoscopic cholecystectomy for subvesical bile ducts: A case report

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The subvesical bile ducts are important from the potential risk for bile leakage.

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It is difficult to identify the subvesical bile ducts intraoperatively.

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Fluorescent cholangiography visualized the subvesical bile ducts clearly.

Introduction

The subvesical bile ducts are located in the peri-hepatic connective tissue of the gallbladder fossa. Injury of the subvesical bile ducts provokes the severe complication of bile leak. Until now, fluorescent cholangiography has been employed during hepatobiliary surgery. Herein, we report the detection of subvesical bile ducts by fluorescent cholangiography during laparoscopic cholecystectomy.

Presentation of case

A 63-year-old female was admitted to our department for surgery for symptomatic cholelithiasis. The subvesical bile ducts were not observed on drip-infusion cholangiography with computed tomography. Immediately following induction of anesthesia, 2.5 mg of indocyanine green was intravenously injected. Fluorescent cholangiography demonstrated two thin aberrant bile ducts during dissection of Calot’s triangle. We considered them to be subvesical bile ducts. We ligated them with clips, divided them, and then performed laparoscopic cholecystectomy using a standard procedure. The patient had a good post-operative recovery without bile leakage. Postoperative laboratory test results were all within normal limits. Computed tomography revealed no dilatation of the intrahepatic bile duct after laparoscopic cholecystectomy. The patient was discharged on postoperative day 4.

Discussion

Injury to the subvesical bile ducts is one of the most common causes of bile leakage associated with cholecystectomy. Fluorescent cholangiography enabled real-time identification of the thin subvesical bile ducts, which were undetectable by drip-infusion cholangiography with computed tomography.

Conclusion

Fluorescent cholangiography during laparoscopic cholecystectomy may be useful for preventing postoperative bile leakage.

Intraoperative Treatment of Duct of Luschka during Laparoscopic Cholecystectomy: A Case Report and Revision of Literature

Background

Bile leakage still remains a serious complication during cholecystectomies. In limited cases, this complication may occur from injury of the so-called ducts of Luschka. These rare ducts are usually discovered intraoperatively, and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation Case

We present a unique case of a 59-year-old male patient with acute cholecystitis. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum. We report on the use of endoscopic QuickClip Pro® clips (Olympus Medical Systems Corp., Tokyo, Japan) to avoid further more invasive treatment.

Discussion

Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. Many authors have argued the role of relaparoscopy, Diagnosis may be intraoperatively but this option does not seem to occur very often; in fact, there is a lack of data in literature.

Conclusion

This is the first case report of bile leak from duct of Luschka treated during the cholecystectomies with endoscopic clip.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

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Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa.

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Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy.

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Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation.

Introduction

Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation of case

Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

Discussion

This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation.

Conclusion

Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage

OBJECTIVE:

Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage.

METHODS:

Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed.

RESULTS:

Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases.

CONCLUSION:

ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula.

Biliary leakage from gallbladder bed after cholecystectomy: Luschka duct or hepaticocholecystic duct?

Anatomic variations in the biliary tract are common and can cause difficulties when a cholecystectomy is performed. One of the most common ones are hepaticocholecystic ducts and Luschka ducts, connecting the gallbladder or its bed to the bile ducts but distinction between these two types of ducts can be difficult. We do discuss here the differences between these anatomical variations, their origin and their clinical implications. These aberrant ducts may go unnoticed and may require further complementary procedures in case of postoperative biliary leakage. In addition to a careful surgical procedure and an examination of the cystic bed in the end of the intervention, an intraoperative cholangiography should be performed as often as possible.

Duct of Luschka diagnosed by sonography in a patient with bile duct carcinoma and intrahepatic bile duct dilatation

The bile duct of Luschka (BDL) is an anatomic anomaly that is an important cause of bile leakage after bile duct surgery. We report a case of bile duct carcinoma with dilated BDL that was diagnosed by ultrasonography (US). An 83-year-old man presented with an obstructive jaundice. US on admission revealed the presence of a solid hypoechoic mass in the bile duct at the hepatic duct confluence and a branch of the bile duct, about 2-4 mm in diameter, distinct from the dilated right anterior hepatic duct slightly upstream of the tumor. This branch had a spiral structure, extended along the gallbladder bed on the surface of segment 5 (S5) of the liver, and emanated small branches that entered the hepatic parenchyma. There has been no previous report of delineation of BDL by preoperative US.

CT and MR cholangiography: advantages and pitfalls in perioperative evaluation of biliary tree

Recent developments in imaging technology have enabled CT and MR cholangiopancreatography (MRCP) to provide minimally invasive alternatives to endoscopic retrograde cholangiopancreatography for the pre- and post-operative assessment of biliary disease. This article describes anatomical variants of the biliary tree with surgical significance, followed by comparison of CT and MR cholangiographies. Drip infusion cholangiography with CT (DIC-CT) enables high-resolution three-dimensional anatomical representation of very small bile ducts (e.g. aberrant branches, the caudate branch and the cystic duct), which are potential causes of surgical complications. The disadvantages of DIC-CT include the possibility of adverse reactions to biliary contrast media and insufficient depiction of bile ducts caused by liver dysfunction or obstructive jaundice. Conventional MRCP is a standard, non-invasive method for evaluating the biliary tree. MRCP provides useful information, especially regarding the extrahepatic bile ducts and dilated intrahepatic bile ducts. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRCP may facilitate the evaluation of biliary structure and excretory function. Understanding the characteristics of each type of cholangiography is important to ensure sufficient perioperative evaluation of the biliary system.

What is the duct of Luschka?--A systematic review

BACKGROUND

Subvesical bile ducts (frequently termed incorrectly "ducts of Luschka") have gained increased clinical recognition in the era of laparoscopic cholecystectomy. Though cited frequently and discussed in the literature, the original description by Hubert von Luschka and many anatomic details of these subvesical bile ducts remain ill-defined.

STUDY DESIGN

A systematic literature search was conducted including publications that described either radiographic features or gross anatomy of bile ducts in close contact with the gallbladder fossa. Of 2,545 publications identified from electronic databases, 116 met inclusion criteria.

RESULTS

Of 116 articles, 13 incorporated a prevalence study design. These 13 articles investigated 3,996 patients, of whom 156 were diagnosed with a subvesical duct for a prevalence of 4%. The prevalence in articles focusing on subvesical bile ducts was greater than in articles studying biliary anatomy in general (10% versus 3%; p<0.0001). Furthermore, of 116 articles, 54 provided detailed anatomic information identifying 238 subvesical ducts, most of which represented accessory ducts. The origin and drainage of these ducts were limited primarily to the right lobe of the liver, but great variation was seen. The mean diameter of the subvesical ducts was 2 mm (range 1-18 mm).

CONCLUSIONS

The term "ducts of Luschka" should be abandoned and should be replaced by the correct term of "subvesical bile duct". The variability in anatomic location of subvesical bile ducts puts them at risk during hepato-biliary operations. A better understanding of ductal anatomy is elemental in preventing and managing operative injury to the subvesical ducts. This review debunks common myths about the so-called "duct of Luschka" and offers a systematic overview of the anatomy of the subvesical bile duct.

Relaparoscopy in minor bile leakage after laparoscopic cholecystectomy: an alternative approach?

PURPOSE

Bile leakage is one of the most important complications of laparoscopic cholecystectomy, and it has been recognized as a major clinical challenge during the last 2 decades. Although endoscopic and percutaneous interventions are widely accepted in the management of bile leakage, relaparoscopy permits the bile drainage adequately and gives direct control of bile leakage site in selected patients.

METHODS

Data for patients with minor bile leakage after laparoscopic cholecystectomy were collected from January 2001 to January 2010. Patients were categorized in 2 groups, nonoperative and relaparoscopy. Clinical presentation, kind of management, and outcomes were evaluated in 2 groups.

RESULTS

After a total of 2652 laparoscopic cholecystectomies, postoperative minor bile leakage occurred in 17 (0.64%) patients. Four patients with minimal leakage were managed by percutaneous drainage alone. Endoscopic retrograde cholangiopancreatography was applied to 4 patients with jaundice, high output bile fistula, and a patient with retained common bile duct stone. Bile leakage was controlled in 3 of the 4 patients. There were 9 patients in the relaparoscopic group to which 1 patient was added after unsuccessful endoscopic intervention. The source of bile leakage in the relaparoscopic cases was defined as 50% from cystic duct stump and 50% from Luschka or accessory ducts. The success rate of bile leakage control after relaparoscopy was 90%. The mean of hospital stay after relaparoscopy was 3 days (range, 2-10 d) and after endoscopic retrograde cholangiopancreatography intervention or percutaneous drainage was 10 days (range, 3-28 d).

CONCLUSIONS

Relaparoscopy is an effective procedure in the management of minor bile leakage after laparoscopic cholecystectomy and can be an alternative approach in selected situations.

Hyperplastic Luschka ducts: a mimic of adenocarcinoma in the gallbladder fossa

Ducts of Luschka are a developmental abnormality found within the gallbladder fossa in up to 10% of cholecystectomy specimens. They are most often encountered by surgeons when injured during laparoscopic or open cholecystectomy, leading to bile leakage and subsequent peritonitis. Histologically, they are typically composed of lobular aggregates of small ductules lined by bland, cuboidal-to-columnar biliary-type epithelium, associated with centrally located, larger ductules surrounded by concentric fibrosis. We have identified 6 cases of florid Luschka duct proliferation in which the ductules demonstrated irregular growth pattern, loss of characteristic concentric fibrosis, and epithelial atypia that strongly suggested the diagnosis of invasive pancreatobiliary adenocarcinoma or metastatic adenocarcinoma involving the gallbladder serosa. Two of the cases were initially diagnosed as invasive adenocarcinoma, whereas the other 4 were sent for consultation to rule out adenocarcinoma. All cases were associated with marked acute and chronic cholecystitis with mucosal ulceration, cholelithiasis, and thickening of the gallbladder wall. The ducts of Luschka were located within the rim of adherent liver in all 6 cases and the gallbladder serosa in 5 cases. Limited follow-up information was available for all patients with no documentation of progressive disease. Awareness and proper recognition of the anatomic location and histologic features are imperative in distinguishing florid ducts of Luschka from both non-neoplastic conditions and most importantly adenocarcinoma.

Temporary placement of a newly designed, fully covered, self-expandable metal stent for refractory bile leaks

Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.

Laparoscopic revisional hepaticojejunostomy for biliary stricture after open repair following common bile duct injury: a case report

INTRODUCTION

Incidence of bile duct injury has been reported more frequently following laparoscopic cholecystectomy.

CASE REPORT

A 43-year-old female with a past medical history of laparoscopic cholecystectomy that was converted to open because of a common bile duct injury now presents with a stenosis at the hepaticojejunostomy that is causing recurrent cholangitis episodes. After the lysis of adhesions and dissection of the anastomotic area, a stricture was identified. The authors exposed and redid the hepaticojejunostomy with 4-0 Monocryl sutures without tension. The follow-up period was unremarkable. No leaks were documented, and the patient was discharged home on postoperative day 3.

CONCLUSION

After percutaneous or endoscopic procedure failure for the treatment of hepaticojejunostomy strictures, the laparoscopic redo anastomosis is safe and feasible when performed by surgeons who are strongly trained in advanced laparoscopic surgery.

Surgical management of segmental and sectoral bile duct injury after laparoscopic cholecystectomy: a challenging situation

BACKGROUND

Injury to a segmental or sectoral bile duct is a rare event in laparoscopic cholecystectomy; its diagnosis and management may be difficult.

PATIENTS AND METHODS

Between April 1998 and December 2006, 73 patients referred to the author's tertiary center for management of postcholecystectomy biliary complications were studied. The patients with segmental/sectoral bile duct injury were divided into two groups: injury to a duct which drains at least one Couinaud segment (type 1) or injury to a minor biliary radical in the gallbladder fossa (type 2). Beside the management of concomitant vascular or other biliary injury, type 1 segmental/sectoral duct injury was repaired by biliary-enteric anastomosis and type 2 by oversewing.

RESULTS

Ten out of 73 referred patients had segmental/sectoral duct injuries (eight type 1, two type 2). Despite multiple radiological imaging and endoscopic procedures, in seven patients, the lesion was identified only by precise surgical dissection. The median length of hospital treatment was 26 (range 9-47) days. One patient died due to sepsis before any definitive treatment. During the mean follow-up of 43 (range 27-111) months, seven patients remained asymptomatic while two patients developed biliary anastomotic strictures requiring intervention.

CONCLUSION

Segmental/sectoral duct injury is difficult to be assessed by conventional radiological diagnostics and should be taken into consideration in every case of bile leakage. Surgical treatment, adapted to the type of lesion, generally results in a favorable outcome.

Current management of biliary leaks

Biliary leak is a troubling complication that arises after a broad range of interventions on the gallbladder, bile ducts, and liver as well as after liver trauma. Fortunately, most biliary leaks are minor. Advances in imaging and minimally invasive interventional techniques have facilitated nonoperative treatment in most cases. The specific clinical scenario dictates diagnosis and treatment of a biliary leak. Prompt diagnosis and treatment lead to optimal clinical outcomes.

Bile leaks from the duct of Luschka (subvesical duct): a review

BACKGROUND

Gallstone disease remains the most common disease of the digestive system in Western societies and laparoscopic cholecystectomy one of the most common surgical procedures performed. Bile leaks remain a significant cause of morbidity for patients undergoing this procedure. These occur in 0.2-2% of cases. The bile ducts of Luschka, or subvesical ducts, are small ducts which originate from the right hepatic lobe, course along the gallbladder fossa, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of postcholecystectomy bile leaks.

METHODS

A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used.

RESULTS

Subvesical bile duct leaks can be detected by drip-infusion cholangiography using computed tomography preoperatively, direct visualization or cholangiography intraoperatively, and fistulography, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography with intravenous contrast postoperatively. ERCP is the most common diagnostic method used. Most patients with subvesical duct leaks are symptomatic, and most leaks will be detected postoperatively during the first postoperative week. Drainage of extravasated bile is mandatory in all cases. Reduction of intrabiliary pressure with endoscopic sphincterotomy and stent placement will lead to preferential flow of bile through the papilla, thus permitting subvesical duct injuries to heal. This is the most common treatment modality used. In a minority of patients, relaparoscopy is performed. In such cases, the leaking subvesical duct is visualized directly, and ligation usually is sufficient treatment. Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks.

CONCLUSIONS

Subvesical duct leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of laparoscopic cholecystectomy. Intraoperative cholangiography does not detect all such leaks. Staying close to the gallbladder wall during its removal from the fossa is the only known prophylactic measure. ERCP and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi, can potentially be used in lowering the incidence of subvesical bile leaks.