肝管损伤的问题

Problems due to Injury of Cysto-hepatic duct

Prof. Dr. R. K. Mishra

Cystohepatic duct

                               
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Cystohepatic duct drains sub-segmental parenchymal distribution of right lobe of liver to the right hepatic duct or cystic duct. Problem occurs at the time of operation when it drains in Cystic duct. At the time of dissection this poorly visualized structure may go unnoticed. Injury results in bile leakage and patient may comes with complication even after 3 to 5 days after operation.

Ducts of Luschka.

Ducts of Luschka drains sub-segmental areas of liver into right hepatic duct. It is typically small in size, also called as subvesical duct. It runs in the submucosa of the posterior gallbladder wall & Gallbladder fossa.

                               
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Complications after Overlooked Injury

·        If size of the duct is small enough leakage may be Inconsequential.

·        Mild leakage will lead to self limiting post operative bile peritonitis.

·        Moderate leakage leads to severe generalized peritonitis.

·        Massive leakage leads to severe peritonitis with bile spillage from port wound.

·        Moderate & massive leakage if not treated immediately patient may die due to shock of peritonitis.

Prevention of Injury.

·        Knowledge of anatomy

·        Good vision.

·        Proper Irrigation.

·        Careful dissection.

·        Routine Intra-operative use of cholangiogram.

Intra-operative treatment of injured duct.

·        Confirmation of diagnosis by repeated intra operative cholangiography for naked segment sign.

·        It should be clipped or ligated.

·        If Pedicle is small enough than it should be cauterized.

Post-Operative Diagnosis of Injured duct.

                               
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·        Traditional exploratory laparotomy to ligate the duct and drain the sub hepatic space.

·        If the duct is small < 2mm in diameter than computerized axial tomography or ultrasound

         guided percutaneous drainage is effective.

·        Now a days endoscopic stent application is also effective mode of treatment.

Why endoscopic stent is effective?

·        After stent application resistance of the sphincter of oddi is reduced.

·        Bile travel through the path of least resistance.

·        Stent can be applied on the same session at the time of diagnostic endoscopy.

·        Endoscopic retrograde cholangiography with placement of stent is effective and

        tolerated by patient.

·        The stent can be removed after 3 months after confirmation of closure.

Conclusion

It is estimated that 10% of people have an accessory ducts within triangle of Calot. Cystohepatic

duct and duct of luschka is one of them. The actual prevalence of a luschka duct is unknown.

So every Laparoscopic surgeon should be careful of it.