Extensive bile duct injury resulting from a laparoscopic cholecystectomy resolved by a Roux-en-Y tri-hepaticojejunostomy: a case report.

INTRODUCTION: Bile duct injuries (BDIs) that occur after a laparoscopic cholecystectomy (LC) are among the most serious iatrogenic injuries and have high morbidity and mortality. They significantly impact the quality of life of the patient. They are one of the most common causes of benign biliary strictures, which can result in serious complications such as recurrent cholangitis or secondary biliary cirrhosis. Although LC is a common operation today, the incidence of BDIs associated with LC is twice that of BDIs resulting from open cholecystectomies. CASE REPORT: In this paper, we present a case report of a patient after LC with the Class III-D injury according to the Stewart-Way classification. The injury was a result of a misleading description from a preoperative ultrasonography and a subsequent misunderstanding of the anatomical conditions of a patient with congenital gallbladder agenesis. The BDI was recognised first day after surgery. Thanks to a prompt transfer to our centre the patient was in a good condition. Biliary reconstruction could be done because there was no serious inflammation or biliary peritonitis at the time of reoperation. Due to the extent of the injury a Roux-en-Y tri-hepaticojejunostomy combined with external transhepatic biliary drains was performed. CONCLUSION: Iatrogenic BDI after a LC is a rare, but potentially life-threatening complication. The main risk factor is the presence of anatomical variants of the biliary tract. Early recognition and treatment in a department with adequately experienced hepatobiliary specialists are crucial for a positive outcome. The most frequent surgical treatment is a Roux-en-Y hepaticojejunostomy.

The most recent recommendations for the surgical treatment of inguinal hernia.

INTRODUCTION: The publication of new guidelines in recent years shows that surgical treatment of inguinal hernia remains topical. The main goal is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain. The main purpose of this article is to summarize the latest recommendations in surgical treatment of the groin hernias, especially in the case of strangulation. METHODS: The authors made literature review of all the guidelines published by the hernia societies, including related articles, in the last ten years. RESULTS: The use of the EHS classification system is suggested. In elective operations, mesh repair is recommended. The Lichtenstein technique is the standard in open inguinal hernia repair. Transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes. Their clear advantages include minimal invasiveness. Mesh repair is recommended also in the case of strangulation, but only in clean and clean-contami-nated operations. A laparoscopic approach should be considered as well. Inter alia, it allows an assessment of bowel viability during the whole procedure. The need of bowel resection is hence lower compared to open surgery. If it is not possible to use the mesh, the Shouldice method is regarded as the best non-mesh repair technique. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is recommended. Hernioscopy is a simple and safe procedure that uses the hernia sac for insertion of a port following insufflation and diagnostic examination. It requires less advanced laparoscopic skills than does emergency laparoscopic hernia repair. It can be performed even by surgeons who lack sufficient experience with laparoscopy. CONCLUSION: In elective procedures, the mesh repair is recommended. It is recommended also in the case of strangulation, but not in a contaminated-dirty surgical field. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is needed.