Introduction

Biliary complications during minimally invasive urological surgeries are rarely described in the literature. Two cases of common bile duct (CBD) injuries have been reported by Canes et al¹ and 1 case of gallbladder perforation was reported by Jaramillo et al,² with no reported cases of accessory biliary ducts injury. This report describes a case of accessory bile duct injury during adhesiolysis and liver mobilization in transperitoneal robot-assisted right partial nephrectomy and summarizes perioperative management of iatrogenic biliary injuries.

Case Description

A 72-year-old female with stage IIIb chronic kidney disease presented to the urologic oncology clinic for evaluation of a 7.5-cm right renal mass. The mass on cross sectional imaging was partially endophytic (Figure 1). Past surgical history includes open cholecystectomy, appendectomy, and bilateral tubal ligation. Given the patient’s renal insufficiency and size of the mass, a right partial nephrectomy with transperitoneal approach was recommended.

Figure 1. Preoperative CT imaging showing anterolateral mass in right inferior renal pole.

Pneumoperitoneum was achieved using a Veress needle, and one 8-mm robotic trocar was placed and used to visualize the operative field. There were extensive bowel and omental attachments to the anterior abdominal wall and adhesions on the superior and anterior liver surfaces. We proceeded to place 3 additional robotic ports and 1 laparoscopic assistant port. The liver edge was found to be densely adherent to the omentum. It was superficially dissected with robotic scissors. Small amounts of green fluid were then noted in the surgical field. General surgery was consulted intraoperatively. A hepatic duct or CBD injury was unlikely due to a superficial dissection plane. No bowel injury was noted. No clear source of green discharge could be identified. It was recommended to place a drain in the right upper quadrant and observe the patient clinically. We continued to dissect the right renal hilar, and identify the renal mass borders with intraoperative renal ultrasound. The partial nephrectomy was performed with gross negative margin and excellent hemostasis after renorrhaphy.

Postoperatively, the patient was monitored for drain output, right upper quadrant pain, nausea, emesis, fever, chills, and jaundice. The patient had only occasional nausea. Hepatic function panel was normal on postoperative day (POD) 1. Drain outputs were nonbilious averaging 300-500 mL in POD1 and 2. Output became bilious with no increased volume in POD3. The drain fluid showed elevated bilirubin of 69 and normal triglyceride and creatinine. Gastroenterology was consulted for bile leak. Endoscopic retrograde cholangiopancreatography (ERCP) was performed on POD5. The cholangiogram showed an apparent bile leak despite intact CBD and hepatic biliary ducts, indicating a likely Luschka duct leak (Figure 2). Sphincterotomy was performed, and one 10F by 7-cm transpapillary stent was placed in the CBD. The patient tolerated the procedure well and was discharged on POD8. Surgical drain was left in place at discharge with continued bilious output. At the 3-week postoperative visit, the patient had no complaints. Surgical drain output was nonbilious and less than 20 cc per day, and the drain was removed in the office. The patient underwent repeat ERCP at 3 months postoperatively for stent removal, which showed dilation of the main extrahepatic bile duct with no apparent leak (Figure 3).

Figure 2. Endoscopic retrograde cholangiopancreatography on postoperative day 5. There was extravasation of contrast from the biliary tree, but the exact location could not be well visualized.

Figure 3. Repeat endoscopic retrograde cholangiopancreatography for biliary stent removal at 3 months postoperatively showing dilated main extrahepatic bile duct with no bile leak or downstream obstruction.

Discussion

Diagnosis and management of iatrogenic biliary injury are mainly described in the context of laparoscopic cholecystectomy. In urological cases, patients with previous cholecystectomy have a higher risk of iatrogenic biliary injury due to postoperative dilation of the biliary tree. Overall perioperative management of biliary injuries has been summarized in Figure 4.

Figure 4. Algorithm for management of biliary injuries during robotic or minimally invasive urologic procedures. CT indicates computerized tomography; ERCP, endoscopic retrograde cholangiopancreatography; MRI, magnetic resonance imaging.

For bile duct injuries that are recognized intraoperatively, it is recommended to perform a prompt cholangiography and explore the CBD. CBD injury or transection usually requires anastomosis and reconstruction by a biliary surgeon. If an insult to an accessory bile duct is visible, tying off the bile duct and placing a surgical drain will provide good control of the leak.³ If the extent of injury is small or the injury was unrecognized intraoperatively, bile leaks can be managed by placing a biliary stent during ERCP on a later date.⁴ A biliary stent facilitates the preferential flow of bile and reduces intrabiliary pressure.⁵

For gallbladder injuries, small contusions or laceration may be managed conservatively. However, cholecystectomy is the definitive procedure of choice if there is apparent leak, large laceration, or gallbladder perforation.⁶ CT imaging can be useful in identifying discontinuity of the gallbladder wall postoperatively, but it should not delay cholecystectomy if bile peritonitis is present.

Only 2 cases of bile duct injuries during minimally invasive urological procedures have been described in literature. Canes et al reported a case of CBD injury during mobilization of the hepatic flexure while creating an Indiana pouch after radical cystectomy, and another case of CBD injury during lysis of adhesions in the undersurface of the liver in right partial nephrectomy.¹ In the first case, the injury to the CBD was able to be visually identified and repaired intraoperatively without additional interventions. In the second case, the patient required placement of a surgical drain, ERCP, and biliary stenting in addition to intraoperative CBD repair. Jaramillo et al reported a case of gallbladder perforation secondary to Veress needle placement during a robot-assisted right simple nephrectomy.² The planned procedure was aborted due to CO₂ air embolism in the patient, and the patient developed biliary peritonitis on POD3. The patient subsequently underwent diagnostic laparoscopy and cholecystectomy.

Our patient had extensive adhesions from previous abdominal surgeries, and bile leak was observed during adhesiolysis between the liver and the omentum. Absence of a native gallbladder made it difficult to access the biliary tree and perform an intraoperative cholangiography, but no injuries to major biliary structures were visualized. In this case, injury to an accessory bile duct, such as a Luschka duct, was most likely given the location and depth of the dissection plane. The patient had an asymptomatic bile leak and remained stable. However, surgical drain placement and ERCP were clinically warranted given high output and risk of biloma formation. The patient made a full recovery with resolution of leak via ERCP with biliary stent placement.

Conclusions

This is the first case report of accessory bile duct injury during transperitoneal robot-assisted right partial nephrectomy. We emphasize the higher risk of biliary injuries in right-sided nephrectomy procedures in patients who have had cholecystectomy. When bile leak is limited in size and does not involve CBD, delayed repair with ERCP and external drainage of biliary tree in the interval is safe and effective.