Laparoscopic cholecystectomy (LC) has been established as a standard surgical procedure for treating benign gallbladder diseases over the last three decades. LC is a minimally invasive surgery, but it can induce various surgical complications that were uncommon in the era of open cholecystectomy. Bile duct injury is the most common complication associated with LC and has an incidence of around 1%, with diversity in terms of extent and location of the injuries [1-4]. Isolated injuries of the right anterior section (RAS) hepatic duct are a rare form of major bile duct injuries [5,6]. The common causes of this injury include direct cutting or clip clamping of the aberrant RAS duct or thermal injury from irrelevant cauterization [7]. Surgical treatments for such isolated RAS duct injuries are often difficult and disadvantageous considering the psychological and physical impacts. We previously reported two cases of parenchymal atrophy induction through hepatic sectional portal vein embolization (PVE) in patients suffering from isolated hepatic sectional duct injury following LC [8,9]. We herein present a rare case of successful nonsurgical treatment for isolated RAS injury following LC through hepatic parenchymal induction therapy using PVE.

A 48-year-old female patient underwent LC for chronic calculous cholecystitis; the LC procedure was completed uneventfully according to standard techniques (Fig. 1). Two days later, the patient complained of abdominal pain and fever. Magnetic resonance cholangiography (MRC) was performed, in which the RAS duct was observed to be transected at the hilar level with a slight dimpling at the proximal bile duct (Fig. 2A, B). This finding suggested the presence of an aberrant RAS duct at the hepatic hilum. On day 4 after surgery, dynamic computed tomography (CT) of the liver showed a slight dilatation of the RAS duct with a small amount of fluid collection at the hepatic hilum, which indicated intraoperative clipping-ligation of the RAS duct (Fig. 2C, D). Sequential abdominal ultrasonography follow-up showed progressive accumulation of abnormal fluid at the hepatic hilum, indicating bile leak following slippage of the clips at the RAS stump. Three weeks after LC, a percutaneous pigtail catheter was inserted to evacuate biloma. Endoscopic retrograde cholangiography (ERC) was performed upon suspicion of bile leak from the aberrant RAS duct, but no bile leak was identified at the time of the ERC procedure (Fig. 3). These findings suggest that the source of the bile leak was the damaged RAS duct. The amount of abdominal catheter drainage was around 200–300 mL/day, which decreased to 100 mL/day 6 weeks after the LC.

Figure 1. Perioperative findings of the gallbladder. Liver computed tomography shows no abnormal findings except cholecystitis (A, B). Laparoscopic cholecystectomy was performed uneventfully, with clipping of the cystic duct stump. There was no evidence of bile leak from the dissected surface (C, D).

Figure 2. Early postoperative imaging study findings. Magnetic resonance cholangiography performed two days after surgery showed that the right anterior section duct was transected and ligated at the hilar level, with a slight dimpling at the proximal bile duct (A, B). Liver dynamic computed tomography showed dilatation of the right anterior section duct (C, D).

Figure 3. Pre-embolization computed tomography findings of the liver. The right anterior section parenchyma occupied approximately 25% of the total liver volume (A, B), with normal branching anatomy of the right portal vein (C, D).

This bile leak was regarded as intractable bile leak from the injured RAS duct; thus, we decided to treat it through hepatic parenchymal induction after assessment of the sectoral liver volume and portal vein anatomy (Fig. 4). The RAS portal vein was percutaneously embolized through an ipsilateral approach (Fig. 5). From day 2 after PVE, the amount of abdominal drainage decreased markedly to less than 50 mL/day. Follow-up CT scan performed 3 days after PVE showed complete occlusion of the RAS portal vein branches (Fig. 6). Hepatobiliary scintigraphy showed no evidence of abnormal bile collection (Fig. 7). Three weeks after PVE, the pigtail catheter was removed because the drainage had ceased for 5 days. The pigtail catheter was thus retained for an overall duration of 6 weeks and up to 4 weeks after PVE. Three months after PVE, the RAS parenchyma showed further atrophy (Fig. 8), and the patient was free of other complications 6 months after the LC (Fig. 9). We plan to follow-up with this patient yearly for a total of 5 years in accordance with the routine surveillance protocols for biliary complications.

Figure 4. Endoscopic retrograde cholangiography images showing no evidence of the bile leak without visualization of the right anterior section duct.

Figure 5. Percutaneous portal vein embolization. The right portal vein was punctured through an ipsilateral approach (A, B). Embolic materials were filled in the peripheral branches of the right anterior section portal vein (C, D).

Figure 6. Follow-up computed tomography scan acquired 3 days after embolization showed complete occlusion of the right anterior section portal vein branches (A, B). No bile leaks were present at the hepatic hilum containing the pigtail catheter (C, D).

Figure 7. Hepatobiliary scintigraphy performed 4 days after embolization showed no evidence of abnormal bile collection with maintenance of the pigtail catheter. ANT, anterior.

Figure 8. Follow-up computed tomography scan obtained 3 months after embolization showed complete occlusion of the right anterior section portal vein branches (A) and no accumulation of bile at the hepatic hilum (B).

Figure 9. Hepatobiliary scintigraphy performed 5 months after embolization showed uneventful drainage of the hepatobiliary system with faint filling defects at the right anterior section of the liver. ANT, anterior.

Most major bile duct injuries are detected during LC procedure or within a few days after surgery; they may also be occasionally detected late owing to the absence of significant symptoms and signs [1-10]. An isolated RAS duct injury is a rare complication because the RAS duct is typically not exposed during the LC procedure unless there is a rare aberrant anatomy. Based on our experience, the estimated incidence of LC-induced isolated RAS duct injuries is far lower than 0.1%.

When an LC-induced bile duct injury is suspected, the first imaging study performed is dynamic liver CT because of its readiness and availability of detailed intra-abdominal information, such as biloma formation, combined vascular injury, and other findings. The next definitive imaging study is MRC because it provides information on the complete configuration of the biliary tree [11,12]. In contrast, ERC may result in erroneous omission of an isolated injury of the segmental/sectional bile duct [5,6]. The presence of bile leak despite normal ERC findings is a diagnostic dilemma, which supports the diagnostic incompleteness of ERC.

In case of bile leak from the injured hepatic duct, drainage should be induced to prevent infection. Percutaneous transhepatic biliary drainage (PTBD) is the best drainage procedure to control bile leaks, but it is often infeasible because the intrahepatic bile ducts are not dilated in a majority of patients undergoing LC. If a Jackson–Pratt-type abdominal drain is inserted during the LC procedure, it should be affixed securely with firm attachment to the skin to prevent accidental removal of the abdominal drain. Otherwise, percutaneous catheter drainage should be performed to evacuate the bile leak.

After the percutaneous bile drainage procedure is completed, abdominal CT scan and hepatobiliary scintigraphy should be performed to assess the abdominal status and extent of bile duct injury. Following thorough review of the dynamic CT, MRC, and hepatobiliary scintigraphy findings, we confirmed that the bile duct injury site was located deeply within the hepatic hilum in the present case. Because this injury site was deeply seated and the surrounding tissues were necrotic due to biloma formation, it was technically not possible to perform primary biliary reconstruction or Roux-en-Y hepaticojejunostomy. Surgical removal of the bile-leaking RAS parenchyma is disadvantageous considering the benign nature of bile duct injuries. Therefore, nonsurgical treatments would be the management choice where possible.

We have reported the effectiveness and usefulness of hepatic atrophy induction treatment for isolated segmental/sectional bile duct injury following LC [8,9]. There are two primary mechanisms associated with hepatic parenchymal atrophy, namely deprivation of portal blood flow and bile duct obstruction. Induction of hepatic parenchymal atrophy consists of three steps. The first step is local control of the bile leak through abdominal drainage or PTBD, which prevents bile leak-associated infection. The second step is percutaneous embolization of the corresponding segmental/sectional portal branch, which effectively inhibits the quantity and quality of bile production in the involved hepatic parenchyma [13,14]. Such selective PVE appears to be more technically demanding than the usual right liver PVE. The last step is induction of spontaneous closure of the leak site through heavy adhesion. Once the bile leakage ceases, there are no further procedures except removal of the abdominal drainage or PTBD catheter. We empirically removed the abdominal drain at 2 to 3 weeks after cessation of the bile leak. If a PTBD catheter had been inserted, it would be reasonable to remove the abdominal drain after a series of test clamping of the PTBD catheter. After these three steps, the segmental/sectional intrahepatic duct can be dilated, but no further dilatation was observed in the follow-up imaging studies. In our experience, the three-step procedures usually require about 3 months.

In conclusion, based on our experience with the present and other preceding cases, selective PVE combined with percutaneous drainage of the bile leak can be used to effectively treat LC-induced isolated RAS duct injuries.

There was no funding related to this study.

All authors have no conflicts of interest to declare.

Conceptualization: SHJ, SH. Data curation: SHJ. Formal analysis: All. Investigation: All. Methodology: All. Project administration: SHJ, SH. Resources: SH. Software: SH. Supervision: SH. Visualization: SHJ, SH. Writing – original draft: All. Writing – review & editing: SHJ, SH.