Four days after laparoscopic cholecystectomy, a patient develops jaundice and bilious drain output. MRCP shows complete transection of the common hepatic duct just above the cystic duct confluence with free flow of bile into the peritoneal cavity. After initial stabilization and percutaneous drainage, the definitive procedure of choice performed by a hepatobiliary surgeon is:

• A Endoscopic placement of multiple plastic stents across the transection
• B Roux-en-Y hepaticojejunostomy ✓
• C Primary end-to-end repair of the duct over a T tube
• D Choledochoduodenostomy

Explanation

A completely transected or ligated major duct cannot be managed endoscopically because there is no luminal continuity for stenting, which suits partial injuries and cystic duct leaks. Primary end-to-end repair has a high stricture rate from devascularization of the duct. Roux-en-Y hepaticojejunostomy to healthy ducts above the injury gives durable results and is the accepted standard for complete transection, whether immediate or delayed after controlling sepsis.

Reference: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.