Retroperitoneal bile leak after laparoscopic cholecystectomy

Abstract

Bile duct injury (BDI) is a well-recognised complication of laparoscopic cholecystectomy (LC). Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. This manifests as non-specific abdominal pain and fever occurring several days after the surgery. It can be managed by laparoscopic washout with or without bile duct repair. We present a rare case of retroperitoneal bile leak post-LC. The mechanism of injury here was likely partial avulsion from excessive traction of the cystic duct during intraoperative cholangiogram. Diagnosing retroperitoneal bile leak can be difficult because it is extremely rare and the presenting symptoms can be similar to an intraperitoneal bile leak. A high index of clinical suspicion is required. In cases of suspected bile leak, any mismatch between the exploratory laparoscopic findings and imaging findings should alert surgeons to consider the rare possibility of a retroperitoneal bile leak.

A Case Report and Literature Review of Icterus Marginatus: Demarcated Subcutaneous Jaundice, A Sign of Retroperitoneal Bile Leak After Laparoscopic Cholecystectomy

“…One patient had a spontaneous perforation of posterior CBD, another was due to gallbladder perforation, and the last case had no apparent reason for the skin discoloration as no source was identified, i.e., no leak, perforation, or fistula communicating to the peritoneum. This agrees with the literature that most causes of bile leak are iatrogenic, and the most common site is the cystic stump [11][12][13]. Most patients had skin discoloration localized to the right flank and groin and were seen postoperatively within two to five days.…”

“…Despite the significant intra-abdominal pathology of this skin demarcation, all patients had good outcomes and went home except for one who passed away due to pulmonary issues. In one case, the patient's outcome was not mentioned [13][14][15][16].…”

“…It manifested first in the navel because this part is thinner than the rest of the abdominal wall. The bile tracking from the retroperitoneum along the fascial planes is formed by the embryological facial planes [5,[10][11][12][13].…”

“…Therefore, one should have a high clinical suspicion of retroperitoneal leak upon finding icterus marginatus. Lim et al proposed an algorithm to help surgical teams identify future retroperitoneal bile leaks [13]. Figure 5 shows the algorithm for CBD leaks.…”

Fluoroscopic Evaluation of the Bile Ducts: Anatomic Variants, Benign and Malignant Pathologies and Bile Leaks: Part II

“…The common causes of bile duct leaks are postcholecystectomy with a leak from the cystic duct (most common cause), which occurs in approximately 0.1% to 0.6% of patients undergoing laparoscopic cholecystectomy; bile duct injury from surgery; and trauma. On cross-sectional imaging, a biloma is detected, which indicates a bile leak 5,6. Bile leaks also can be detected and/or confirmed on hepatobiliary iminodiacetic acid (HIDA) scans.…”