Initial management of suspected biliary injury after laparoscopic cholecystectomy.

Although rare, iatrogenic bile duct injury (BDI) after laparoscopic cholecystectomy may be devastating to the patient. The cornerstones for the initial management of BDI are early recognition, followed by modern imaging and evaluation of injury severity. Tertiary hepato-biliary centre care with a multi-disciplinary approach is crucial. The diagnostics of BDI commences with a multi-phase abdominal computed tomography scan, and when the biloma is drained or a surgical drain is put in place, the diagnosis is set with the help of bile drain output. To visualize the leak site and biliary anatomy, the diagnostics is supplemented with contrast enhanced magnetic resonance imaging. The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated. Most often, a combination of percutaneous and endoscopic methods is used for control of contamination and bile leak. Generally, the next step is endoscopic retrograde cholangiography (ERC) for downstream control of the bile leak. ERC with insertion of a stent is the treatment of choice in most mild bile leaks. The surgical option of re-operation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient. The patient's failure to recover properly in the first days after laparoscopic cholecystectomy should immediately raise suspicion of BDI and this merits immediate investigation. Early consultation and referral to a dedicated hepato-biliary unit are essential for the best outcome.