Right Posterior Sectoral Bile Duct Injuries Post Laparoscopic Cholecystectomy: Wait or Operate?

Background: Right posterior sectoral hepatic duct anomalies are seen in about 6%-8% of population. Management strategies are still controversial. Our aim was to study the management of right posterior sectoral bile duct injuries during laparoscopic cholecystectomy in a specialized center. Patients end Methods: Ten cases were treated between 2005 and 2010 for injuries of right posterior sectoral bile duct injuries and were followed up for a median of 20 month (range, 12-60 months). Demographic data, clinical presentation, management and outcome were reviewed. Results: In three cases, bile duct injuries were immediately discovered, two were converted from laparoscopic to open laparotomy, with attempt to do bilioenteric anastomosis in one case, and stone removal from the bile duct in the second case. The third case was just managed by an intraperitoneal drain. The mean time of referral after index surgery was 12 days. The main presentation on referral was bile leak in 7 cases (70%), biliary peritonitis in 2 cases (20%), and ascending cholangitis in one case (10%). Post referral management of biliary injury included endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage and surgery. In seven cases (70%)) ERCP could identify the sectoral bile duct injury. In 8 cases (80%)) magnetic resonance cholangiopancreatography (MRCP) was done and could identify sectoral right duct injury. Six cases (60%)) were managed by ERCP and sphincterotomy with stenting. One of them needed stone extraction. Four of these cases (67%) needed no further management. Four cases (40%) needed bilioenteric anastomosis as definitive treatment. Six cases (60%)) did well without surgical bilioenteric anastomosis, four of ihem (67%o) after ERCP and stenting, one case after surgical peritoneal lavage and drainage and one with conservative management after intraperitoneal drain placement at the primary center. No significant morbidity or mortality apart from one case of incisional hernia. Conclusion: successful management of isolated right posterior sectoral duct injury after laparoscopic cholecystectomy requires adequate identification of the injury and multidisciplinary treatment. 60%) of the cases can be treated successfully with proper drainage and non surgical procedures.