Background
“Cystic duct remnant” means 1cm or more cystic duct is left out during cholecystectomy. This entity comprising 17-25% of post cholecystectomy syndrome was 1st described by Florcken in 1912. Remnant gallbladder or cystic duct is left out to avoid bile duct or hepatic vascular injury during difficult calot’s dissection. Symptomatic cystic duct remnant requires surgical treatment. Laparoscopic excision has become the preferred choice where expertise is available. Laparoscopic cholecystectomy is now an established and safe procedure. However 2.6% serious post-operative complications have still been documented in the literature. Few cases of hepatic sub capsular haematoma, an unusual life-threatening complication have been reported. Associated ischaemic hepatitis has also been reported rarely. But no such complication after excision of cystic duct remnant is found in literature search.
We had encountered with a hepatic sub capsular haematoma of the right lobe of liver with symptoms of ischaemic hepatitis occuring after laparoscopic excision of symptomatic remnant cystic duct with calculi.
Method
A 37 years old lady presented with recurrent pain upper abdomen and mild intermittent fever for six months. She had undergone laparoscopic cholecystectomy in 2010. Ultrasound and MRCP revealed symptomatic remnant cystic duct with calculi. After complete work up she was planned for laparoscopic excision of the cystic duct remnant. Laparoscopic approach was planned and trocars were placed similar to laparoscopic cholecystectomy. Post operative adhesions were cleared and cystic duct was found to be inserted lower down and in postero-lateral wall of CBD. Impacted stone at the junction of cystic duct and CBD was niched out. Cystic duct remnant was dissected out and excised. Per operative cholangiogram was done to exclude calculus or luminal pathology in the CBD. The stump was sutured with 3-0 polyglactin 910. Sub-hepatic drainage was applied and the ports were closed.
Results
Immediate post-operative period was uneventful. However after 24hrs the patient developed sudden acute pain over the right hypochondrium and right lower chest with nausea. She was restless. On examination she was found to be pale. Investigations showed drop in Hb% level, grossly deranged LFT, raised WBC and polymorph count. USG revealed hepatic Sub capsular hematoma of right liver without intra-abdominal collection. CECT revealed a large Sub capsular hematoma on the right lobe of liver. The patient was monitored closely. She was clinically stable and hence conservative treatment with intra venous fluid, antibiotic, analgesic, transfusion of blood cells and FFP was started. Patient responded to treatment. Hemoglobin level recovered gradually and deranged hepatic enzymes came back to normal. Haematoma was regressing. She was discharged ten days after operation. Patient was followed up regularly. Haematoma resolved completely in six months.
Conclusion
Hepatic subcapsular haematoma is a life-threatening complication. Ischaemic hepatitis adds to the complexity of the condition. We have encountered this complication following excision of cystic duct remnant not found in literature search. Experience to treat this complex complication is limited due to limited experience from the literature. Conservative or interventional treatment is decided on clinical
haemodynamic presentation in association with haematological and radiological parameters. Our patient responded to conservative treatment.
Comments
No have any comment !