Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

Alfredo Torretta; Dimana Kaludova; Mayank Roy; Satya Bhattacharya; Roberto Valente

doi:10.1016/j.ijscr.2022.107110

Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

Int J Surg Case Rep. 2022 May:94:107110. doi: 10.1016/j.ijscr.2022.107110. Epub 2022 Apr 21.

Authors

Alfredo Torretta¹, Dimana Kaludova², Mayank Roy³, Satya Bhattacharya⁴, Roberto Valente⁵

Affiliations

¹ Department of General Surgery, "Val Vibrata" Hospital, ASL Teramo, Italy; HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
² HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK. Electronic address: [email protected].
³ HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
⁴ HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK. Electronic address: [email protected].
⁵ HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK; Department of Surgery and Interventional Science, University College London, UK; Department of Surgery, Ospedale Policlinico San Martino Genova, Italy. Electronic address: [email protected].

Abstract

Background: Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.

Methods & case report: We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.

Discussion & conclusion: The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

Keywords: Burst abdomen; Evisceration; Laparoscopic cholecystectomy bile duct injury; Negative pressure wound therapy (NPWT); Open abdomen; Vacuum assisted wound closure and mesh-mediated fascial traction (VAWCM).