A 34 year old woman is brought to the operating room with a diagnosis of acute on chronic cholecystitis. Pre-operative blood tests revealed WBC 15K, total bilirubin 1.8, normal ALP. An ultrasound showed a thickened gallbladder wall, pericholecystic fluid, positive Murphy sign.
A 30-minute lysis of adhesions was needed to visualize the gallbladder. Once this was done, the gallbladder appeared necrotic and distended with very friable tissue.
According to the operative report, the cystic artery was densely adherent to the cystic duct, therefore it was clipped multiple times to ensure no bleeding was present in the gallbladder. A cystic duct structure was then isolated, and clipped proximally. A cholangiogram was performed. Contrast flowing into the common bile duct and the duodenum was visualized. However, despite multiple attempts, the proximal hepatic and the biliary bifurcation were not visualized. Following completion of the cholangiogram, cystic duct and cystic artery were divided, and the gallbladder was removed. The patient was discharged to home.
Few days later, the patient presented to the emergency department with complaints of abdominal pain. Liver function tests were consistent with biliary obstruction, and an ultrasound showed intra-hepatic biliary dilation.
Ultimately the patient was diagnosed with an injury of the CBD, Strasberg type E2, and underwent exploratory laparotomy and Roux-en-Y hepatico-jejunostomy (done by a different surgeon), 15 days after her cholecystectomy. The post-operative course was uneventful. The hapatico-jejunostomy has been performed 6 months ago.
This patient clearly had a hostile abdomen, and the gallbladder was severely inflamed. The surgeon did obtain an intra-operative cholangiogram. Should the transection of the common bile duct be considered a technical error or negligence?
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Do you believe there might have been medical error?
There are a number of strategies that a surgeon can use to avoid injuries to the CBD, such as completion of an intra-operative cholangiogram, verification of critical view of safety, intra-operative consult with more experienced surgeon, use of subtotal cholecystectomy, etc. Use of at least one of those strategies is particularly important especially in difficult cholecystectomies, such as the one described in this case. The surgeon opted to use a cholangiogram, which was appropriate. However, he dismissed the worrisome findings provided by the cholangiogram – then why to obtain a cholangiogram at all if you are not going to act on the information provided? If you are unable to visualize the proximal portion of the biliary tree, you must assumed that your catheter has been inserted not in the cystic duct, but in the CBD. The surgeon should have re-evaluated the anatomy and call in a more experienced surgeon at this time.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A transection of the CBD would have been avoided if the surgeon had re-evaluated the anatomy upon review of the intra-operative cholangiogram. In a sense, at the time of the cholangiogram the CBD had already been injured, since a catheter had been inserted in it. However this injury would have been partial, and would have not required a major reconstructive procedure (as opposed to the complete transection, which required an hepatico-jejunostomy). Based on this summary it sounds like there were no early post-operative complications following the hepatico-jejunostomy. However long-term complications are still possible (e.g. stricture of the hepatico-jejunostomy, increased risk of bowel obstruction, risk of hernias, etc).
What makes you a good expert for this case?
As a general surgeon I am very familiar with this type of surgery. I perform major hepato-biliary surgery. I have also served in the past as an expert witness for other cases of CBD injury
How often do you encounter cases similar to this one in your practice?
I perform about a cholecystectomy a month
Do you believe there might have been medical error?
The operation was properly indicated. The surgeon performed a cholangiogram, but one of the reasons to perform a cholangiogram is in fact to verify that the correct biliary anatomy has been identified. Specifically, the surgeon must verify that the cholangio catheter is inserted in the cystic duct and not the CBD. Opacification of the distal CBD only with no opacification of the proximal biliary tree suggests that in fact the catheter has been inserted in the CBD.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
: If the surgeon had recognized that the catheter had been inserted in the CBD, he could have avoided a complete transection, that eventually required a hepatico-jejunostomy. The ductotomy made to insert the catheter could have been addressed with primary repair if the CBD was dilated, or with placement of a T-tube. Either maneuver would have avoided the need for a subsequent major operation.
What makes you a good expert for this case?
Multiple years practicing surgical oncology
How often do you encounter cases similar to this one in your practice?
I have cared for a number of patients with complex bile duct injuries
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