Journal of the Louisiana State Medical Society
Figure 1: Panel 1a: Intraoperative T-tube cholangiogram showing apparently normal bile duct anatomy without any leak while the patient continued to have copious bile leak. Right anterior hepatic duct (white arrowhead) was mistaken as right main hepatic duct. Right posterior hepatic duct (black arrowhead) was mistaken as left main hepatic duct. Black arrow shows common bile duct and white arrow with black outline shows cystic duct stump. Panel 1b: Postoperative ERCP findings showing again no leak and similar anatomical findings as during surgery (patient continues to have copious bile leak). Panel 1c: Cholangiogram 50 days after surgery via J-P drain showing the exact location of leak from a transected left main hepatic duct (white arrow) without any relation to rest of biliary system.
Figure 2: Panel 2a: Injection directly into left biliary system during final operation showing the opacification of transected left main hepatic duct (white arrow). Panel 2b: Injection via T-tube during final operation showing the right anterior hepatic duct (white arrowhead), the right posterior hepatic duct (black arrowhead), and the left main hepatic duct (white arrow) simultaneously in one image.
(HIDA) scanwas not considered for this patient, since it was already known that the patient had bile leak, and a HIDA scan is not accurate enough to show the exact anatomical site of the leak. The patient was taken back to the operating room. After identifying the retracted left hepatic duct that was the source of bile leak, a confirmatory sequential chol- angiogram via transected left hepatic duct (Figure 2-A) and through the T-tube was performed. The contrast was kept in the transected duct while injecting the contrast via the
T-tube in order to reconstruct the whole bile duct anatomy in one picture (Figure 2-B). After ascertaining the detailed anatomy, a Roux-en-Y selective left hepaticojejunostomy was performed. The patient did well postoperatively, and the bile leak was resolved. Subsequently, both the T-tube and J-P drain were removed a few days after the surgery. The patient is doing well 43 months after the surgery.
204 J La State Med Soc VOL 166 September/October 2014
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