Introduction: Combined vasculo-biliary injuries, including biliary duct, hepatic artery and portal vein, arevery rare, but severe complicationsafter cholecystectomy due to their high morbidity and mortality. Case presentation: We present a D4dpv (according to Hanover-classification of biliary injuries) biliary tract injury in a 41-years-old lady who underwent an elective laparoscopic cholecystectomy with a conversion for a massive bleeding from portal vein. Total transection of the common hepatic duct, sutured portal vein, narrowed up to 25 % at the near trifurcation with a thrombus to superior mesenteric vein, ligation of right hepatic artery (existing Sg4 arterial branch, replaced left hepatic artery and opened arterio-portal shunt) were observed on the second postoperative day when she was referred to our HPB centre with diagnosis of portal vein thrombosis. The portal inflow was restored by means of thrombectomy and reconstruction of portal vein, no liver resection was performed. Biliary reconstruction required suture approximation of both hepatic ducts and an end-to-side Roux-en-Y hepatico-jejunostomy. The necrotic lesions in Sg6 and Sg7 gradually converted to cystic lesions on the 30-th postoperative day with no signs of infection. A strict observation is being carried on in order prompt treatment to be issued if necessary. Conclusion: Prompt diagnosis and individual treatment strategy at a tertiary centre in terms of time and type of surgical procedure are of outmost importance whenever a vasculo-biliary injury is presumed.
PG. The pancreatic remnant was mobilized 2e3 cm from the splenic vein and the surrounding tissues. A 2 cm long seromuscular incision is made in the posterior wall of the stomach exposing the gastric mucosa. A submucosal tunnel 2 cm in length is created. A seromuscular continuous circular suture was placed around the gastric incision. The pancreatic remnant was then pulled with slide tension in the seromuscular tunnel into the stomach. Ideally, the pancreatic remnant should pass through a submucosal tunnel into the posterior gastric wall by 2e3 cm. The seromuscular continuous circular suture was tied to the lowest part of the pancreatic stump. Results: The overall mortality, morbidity and pancreatic leakage following PD were 4% (n = 6), 41.2% (n = 61) and 9.6% (n = 15), respectively. The mortality, morbidity and pancreatic leakage were 5.1% (n = 6), 44.8% (n = 52) and 11.2% (n = 13) in the PJ group, and 0%, 28.1% (n = 9) and 6.2% (n = 2) in the PG group (p < 0.05). Conclusions: Submucosal PG with continuous circular suture is a safer method than PJ, following PD at a significantly lower rate of pancreatic leakage, surgical morbidity and mortality. This technique is simple and reduces the risk of pancreatic leakage by removing the danger of suture injury of the pancreas.
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