Iatrogenic CBD injury with bile leakage during cholecystectomy

A 34 year old gentleman had undergone cholecystectomy four weeks earlier. He had suffered an injury to the CBD per op and was referred to us for management. A drain was placed in the sub hepatic space. The bilirubin level in the drain fluid was 53mg/dL. Serum bilirubin was 5mg/dL. The MRCP report showed non visualization of the upper CBD and CHD. A leak was also seen (A: green arrows show the non visualized part of the upper CBD and the CHD while the red arrow marks the leak). CBD cannulation was initially unsuccessful. We were bale to cannulate the pancreatic duct and proceeded to do a transpancreatic papillotomy. That allowed clear visualization and cannulation of the bile duct (B: green arrow shows the guidewire in the CBD and red arrow marks the pancreatic duct opening). Dye injection showed the bile duct (C1 & C2: green arrows), site of leakage (C1 & C2: yellow arrow), the abdominal drain (C1 & C2: red arrows) and the intrahepatic biliary channels proximal to the site of leakage with the guidewir across the leak (C1: white arrows). There was resistance to the papillotome going through the site of leakage and into the right hepatic duct so we dilated the track first (D: green arrows show the dilatation catheter and red arrows show the intrahepatic drain). A 10cm long 10 French plastic stent was placed (E1 & E2: green arrows marking the stent and red arrows show the drainage tube).