Intrahepatic Ductal Rupture and Ectasia

Intrahepatic ductal rupture is a complication that occurs secondary to intraoperative extraction of biliary calculi with Fogarty balloon catheters [55]. With this technique, the catheter is often advanced blindly into the intrahepatic ducts through a choledochotomy. The balloon is inflated and then withdrawn to remove calculi. Intrahepatic ducts may rupture if the balloon is distended beyond the luminal capacity of the duct. The use of fluoroscopy would help to prevent this

Figure 4.32. Intrahepatic ductal rupture. Film from a T-tube cholangiogram demonstrate an amorphous collection of contrast medium in the liver parenchyma due to intrahepatic ductal rupture from extraction of calculi with a Fogarty balloon catheter.

problem, but the necessary equipment may not be available in the operating room. Radiographically, large or small irregular collections of contrast medium can be identified in the liver parenchyma associated with focally dilated intrahepatic ducts (Fig. 4.32). Hepatic abscess may be a sequela of this problem in patients with cholangitis and infected bile. Focal or segmental ductal ectasia, rather than rupture, may result if the balloon is deflated before frank rupture has occurred [19]. The radiographic findings in this circumstance may simulate Caroli's disease.

Hemorrhage

Bleeding after cholecystectomy may be secondary to avulsion or tear of the cystic artery, slippage of the cystic artery sutures, injury to the hepatic artery, laceration of the liver, bleeding from the gallbladder bed after surgery for acute cholecystitis, and rarely, injury to the inferior vena cava or iatrogenic fistulas between the hepatic artery and portal vein [17,20]. One angiographic study showed evidence of vascular injury in 57% of patients with biliary strictures [29]. The presence of portal hypertension increases the risk of vascular injury.

The right hepatic artery is particularly susceptible to injury because of its course, running almost parallel to the cystic duct along the edge of the hepaticoduodenal ligament. Variations in the anatomy of the right hepatic artery also predispose patients to injury. Accidental ligation of the hepatic artery may lead to hepatic infarction [20].

Drainage Tube Problems

T tubes are commonly placed in the common duct after common duct exploration. Since most common duct stones are now removed endo-scopically, the number of patients requiring ductal explorations and T tubes is diminishing. Complications related to T tubes include faulty placement, dislodgment, obstruction, extrusion, breakage, and disintegration. A long proximal arm of a T tube can lead to obstruction, cause biliary obstruction from a portion of the liver, or prevent retained stone passage. Blood clots, calculi, gravel, encrusted material, or kinking can lead to obstruction of the T tube. Obstruction by encrusted material is related to the length of time the T tube has been in place. T tubes may also cause biliary perforation if a limb penetrates the walls. The limbs of the T tube are usually cut obliquely, and the sharp end can erode the bile duct wall, especially if cholangitis has rendered it friable [19].

Plain films of the abdomen may suggest an abnormal position of the tube, and contrast medium can be injected for confirmation (Fig. 4.33).

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