Biliary injury after cholecystectomy in a patient with severe right liver atrophy
A 76-year-old man visited emergency room with right upper quadrant and flank pain. CT revealed calculous cholecystitis without common or intrahepatic bile duct stones. He had not viral hepatitis or previous abdominal pain history. He showed mild fever and normal limit of blood chemistry except leukocystosis with white blood cell count was 13,000. We decided the cholecystostomy for initial treatment of cholecsytitis, after making patient stable and afebrile.\nInitial CT scan showed small mass-like lesion of severely shrunken right hepatic lobe and hypertrophy of the left hepatic lobe (). Right hepatic vein was normally drained to inferior vena cava (), and intrahepatic duct was not dilated. Right hepatic artery and portal vein were not visualized distinctly in CT. GB was identified in a retrohepatic position, and located in beneath the diaphragm with wall thickening demonstrating cholecystitis (). One week after cholecystostomy, cholecystectomy was done. We tried laparoscopic approach with routine 4 port methods, however we could not approach the GB without liver mobilization and position change. Because of severe adhesion of GB with omentum and mesocolon, we decided the open conversion procedure. During the cholecystectomy, excessive bleeding and bile leakage occurred in GB bed requiring two pint of packed red blood cell transfusion. However we could not be sure of hepatic artery or portal vein bleeding. We did not perform liver resection due to absence of pathologic condition of liver parenchyma, and perform bleeding and leakage control by suture ligation. A drain was left in GB fossa and liver dome. On 3rd day after operation, 50 to 100 mL/day of bile drainage was detected in Jackson-Pratt drain. We decided conservative management for bile fistula. CT showed small amount of biloma in GB fossa. Ten day after surgery, the amount of bile drainage increased up to 200 mL/day, and so we decided to perform endoscopic retrograde cholangiopancreatography for therapeutic biliary drainage. The cholangiography revealed nonvisualization of right hepatic duct. The suspicious leakage point was right posterior duct root or branch of segment 4 (). Endoscopic nasobiliary drainage (ENBD) was left in left hepatic duct (). Amount of bile drainage was markedly decreased after procedure and ENBD was removed on 29 day after surgery. He was discharged 36 day after surgery.