La cholangiographie peropératoire au cours des cholecystectomies laparoscopiques

Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report

BACKGROUND

Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy.

CASE PRESENTATION

A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days.

CONCLUSION

Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

Le risque de plaies biliaires au cours de la cholécystectomie par laparoscopie

The incidence of iatrogenic injuries of the bile ducts has increased significantly since laparascopic cholecystectomy became the "gold standard" in the treatment of cholelithiasis. The incidence of major biliary ductal injury ranges from 0.25% to 0.74%, and of minor injury from 0.28% to 1.7%. The cause of the injury is not always clearly identifiable. In more than half the cases, the injury occurs during maneuvers to isolate the cystic duct or to free the gallbladder from the common bile duct. These maneuvers may be more difficult and consequently more dangerous when there is significant inflammation as may be seen in acute cholecystitis, or in case of obesity, cirrhosis with portal hypertension, previous surgery with peritoneal adhesions, or anatomic variations of the hepatic pedicle. Pre-operative evaluation of clinical risk factors should be coupled with intra-operative caution and instrumental evaluation. The increase in frequency of iatrogenic biliary injuries can not be attributed simply to the inexperience of the surgeon or the learning curve as was initially suggested. Many injuries are due, rather, to the surgeon's failure to respect basic technical rules, long established for open cholecystectomy and which should not be modified for the laparoscopic technique. While routine cholangiography does not offer complete protection from iatrogenic ductal injuries, it is essential to visualize the biliary tract whenever a lesion of the ductal system is clearly identified or even suspected. In such cases, facility with the technique of intraoperative cholangiography and a knowledge of the radiological anatomy of the biliary tree are essential for an accurate and complete intraoperative evaluation of the biliary injury. Finally, in the presence of acute or chronic inflammation or other factors for technical difficulty (obesity, cirrhosis, previous surgery, anatomic variations, intraoperative bleeding), the surgeon must not hesitate to consider conversion to an open surgical approach. In such complicated cases, even the open approach is not a guarantee against biliary injury; there is no substitute for experience and caution in biliary surgery.