Bile Duct Injury After Laparoscopic Intraoperative Cholangioscopy

CASE REPORT

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Correspondence: Klaus Mönkemüller, MD, PhD — Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

Abstract

Background: Bile duct injury is a rare but significant complication of laparoscopic intraoperative cholangioscopy and lithotripsy performed during cholecystectomy. Immediate recognition and endoscopic management are essential for favorable outcomes.

Case: A 45-year-old patient admitted with acute cholecystitis underwent emergent laparoscopic cholecystectomy with intraoperative cholangiogram revealing multiple bile duct stones. Direct laparoscopic cholangioscopy with SpyGlass lithotripsy was performed, resulting in bile duct injury with a large bile leak. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with placement of a self-expanding metal stent (Viabil, 8 mm × 60 mm) bridging the injury, followed by a plastic stent through the metal stent to maintain patency and prevent stone-induced occlusion.

Conclusion: ERCP with self-expanding metal stent placement is an effective strategy for immediate sealing of bile duct injuries. The dual-stent approach — metal stent for leak sealing with a plastic stent for patency — addresses both the acute injury and the risk of residual stone obstruction.

Keywords: bile duct injury; bile leak; intraoperative cholangioscopy; choledocholithiasis; ERCP; self-expanding metal stent; laparoscopic cholecystectomy; SpyGlass lithotripsy; biliary stenting

★ Key Clinical Takeaways

Bile duct injury is a potential complication of advanced endoscopic procedures such as intraoperative cholangioscopy and lithotripsy.
ERCP is an effective method for the diagnosis and management of bile duct injuries and bile leaks.
Self-expanding metal stents can effectively seal bile duct injuries and leaks, providing immediate resolution.
Placing a plastic stent within a metal stent maintains patency and prevents occlusion from residual stones or debris — a dual-stent strategy that addresses both the leak and ongoing lithiasis.
Long-term follow-up with planned stent removal at approximately six months is essential to ensure resolution of the injury and to manage any remaining biliary pathology.

Clinical History

The patient was admitted with acute cholecystitis and underwent emergent laparoscopic cholecystectomy. During intraoperative cholangiogram, multiple stones were visualized within the bile duct. A direct laparoscopic intraoperative cholangioscopy was performed (panel B) revealing multiple stones, some of which were impacted within the bile duct. SpyGlass cholangioscopy-lithotripsy was performed. The bile duct subsequently appeared damaged and swollen. An intraoperative cholangiogram revealed a large bile leak (panel D).

Figure 1. Bile Duct Injury After Laparoscopic Intraoperative Cholangioscopy. A. Intraoperative cholangiogram demonstrating multiple stones within the bile duct. B. Direct laparoscopic cholangioscopic view of impacted bile duct stones. C. Cholangioscopy showing stone burden within the bile duct. D. Intraoperative cholangiogram revealing a large bile leak (yellow arrow). E. ERCP demonstrating significant bile leak (yellow arrow) with wire seen exiting through the bile duct injury (green arrow). F. Wire manipulated past the stone and bile leak into the proximal common bile duct and left hepatic system (yellow arrow marks filling defect). G. Self-expanding metal stent (Viabil, 8 mm × 60 mm) deployed bridging the bile duct injury (yellow oval). H. Occlusion cholangiogram through the stent confirming resolution of the bile leak (yellow oval).

Endoscopic Findings

Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a significant bile leak (E, yellow arrow).
A rounded filling defect, consistent with a bile stone, was observed within the bile duct near the area of the injury (F, yellow arrow).
The wire was seen exiting through the bile duct injury (panel E, green arrow).

Endoscopic Technique

ERCP was performed following the discovery of a bile duct injury.
A wire was manipulated past the stone and the bile leak into the proximal common bile duct and left hepatic system (panel F).
An 8 mm diameter, 60 mm long self-expanding metal stent (Viabil) was inserted into the common bile duct, bridging the bile duct injury (G, F, yellow oval).
An occlusion cholangiogram through the stent confirmed resolution of the bile leak (H).
A plastic stent was placed through the metal stent to maintain patency and prevent occlusion from proximal stones. This also aimed to prevent a stone-induced valve mechanism effect.
The patient is scheduled for stent removal in approximately six months. If bile leak persists, a new stent will be inserted.

Discussion

This case highlights a rare but significant complication of laparoscopic intraoperative cholangioscopy for choledocholithiasis: bile duct injury and subsequent bile leak. The immediate recognition and endoscopic management of this complication are crucial for patient outcomes.

The use of a self-expanding metal stent provided immediate sealing of the bile leak, while the placement of an additional plastic stent addressed the concern of continued obstruction from residual stones. The decision to prioritize bile leak sealing over complete stone extraction during the initial ERCP was appropriate given the acuity of the injury and the technical challenges posed by the inflamed duct.

Subsequent follow-up for stent removal and potential further stone management is essential.

References

Cotton PB, et al. Endoscopic management of bile duct injuries. Gastrointest Endosc. 2007;65(6):830-836.
Singhal D, et al. Endoscopic treatment of bile leaks. Curr Opin Gastroenterol. 2013;29(5):540-545.
Davids PH, et al. Bile duct strictures after laparoscopic cholecystectomy: a new challenge for the endoscopist. Gut. 1993;34(9):1260-1262.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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