MCS Case 8 2020

Clinical Presentation:
A 32-year-old man presents to your facility 10 days after undergoing a laparoscopic
cholecystectomy for acute cholecystitis at another hospital. He is complaining of severe pain in
the right upper quadrant along with fever, chills, and scleral icterus, all of which began about five
days ago and have progressively worsened. The heart rate is 120 bpm, blood pressure is 100/70
mmHg ((13.3/8.3 kPa), and respiratory rate is 30. Examination is remarkable for tenderness and
peritonitis in the right upper quadrant and icterus of the sclerae. There are two surgical wounds in
the right upper quadrant, one in the epigastrium, and one just above the umbilicus, all are clean
and healing well. The surgeon who performed the operation is not available for consultation. The
operative report states that the laparoscopic cholecystectomy was uneventful and the surgeon
was able to achieve the critical view of safety before dividing the cystic duct.

Questions:

1. What is the differential diagnosis? What is the most likely diagnosis?

answer

a. post laparascopic cholycystectomy Biloma obstructing extrahepatic ducts

b. post cholecystectomy bile leak
c. stone failed from cyctic duct to CBD
d. Righ Hepatic Duct or CBD injury

2. What are the priorities in caring for this patient?

Answer

a. start giving antibiotics

b. iv fluids
c. pain control
d. do CBC , LFT including bilirubin level and type
e. do imagine for the abdomen : US/CT or MRI
3. What tests can you use to make the diagnosis? What tests can you use to evaluate the
anatomic basis of the diagnosis?

Answer

a. do CBC , LFT including bilirubin level and type

b. do imagine for the abdomen : US/CT or MRI
c. MRCP or cholangiogram to evaluate the site of obstruction
4. What is the “critical view of safety” in laparoscopic cholecystectomy?
Answer

The critical view of safety in laparoscopic cholecystectomy is making sure that

there is two tubal structures which are entering to the gallbladder (Cystic duct and
cystic are artery)

5. Once the patient is stable, how would you care for this injury?

Answer

a. insert ultrasound guided percutaneous drain tube

b. do ERCP
6. If the injury were more severe, how would you care for it?

Answer

Where there is severe injury to the extrahepatic ducts post laparoscopic cholecystectomy

I will do open laparotomy and CBD exploration

7. What would you do in a resource-poor setting if advanced endoscopic modalities were

not available? Discuss various options.

answer

a. US guided percutaneous drain insertion

b. open laparotomy and insertion of T-tube
c. open laparotomy for CBD exploration with intraoperative cholangiogram