Duodenal perforation during lap Chole - Forum

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Sweden surgeon

Duodenal perforation during lap Chole - Ärzteforum

Post#1 »

I did a lap cholecystectomy on a 70 year old woman with symptomatic gall stones. She had one huge stone, about the size of a small egg, and several smaller ones. On exploration, the duodenum pulled up with the gall bladder, but stripped down easily, and the rest of the operation was uneventful. She went home after the operation, but continued to complain of severe pain, no fever or elevated WBC.

Subsequent workup included and US which was normal, and a gastrograffin swallow which showed a questionable leak from the dudenum. Probably from the point where I stripped it down.

Relaparoscoped 24h after copletion of previous operation via the same ports. There was some bile stained fluid under the liver and along the right gutter, but could not identify source. Filled the stomach with methylene blue, and was able to see a small, 3mm perforation in the anterior wall of the duodenum at the junction of the 1st and 2nd parts. There was very little inflammation or fibrinous exudates, and the perforation was clean, without bulging mucosa.

What now? We considered the following:
1. open via a kocher incision and
a: close with omentopexy
b: close with serosal patch
c: put a T-tube through the hole as a duodensotomy.
2. Do a laparoscopic omentopexy and
drain
not drain

Which would you have done, or do you have any other suggestions?


Arizona

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#2 »

I would ask what they would do if they found a positive "Gonser's bubbly bile sign during the LCindicating an acute revelation of a "pre-existing cholecysto/duodenal fisutula"..yeah...that's it!.(not) indicating a tear into the duodenum during LC. If one isn't prepared to convert at that time, should one be less likely to open Postop. PS Gonser is my partner and a good surgeon for the record.

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Surgeon

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#3 »

Open. Suture the perforation -one layer taking big bites. Nothing else.

John Dissector

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#4 »

If this is what you do, why open? I can suture the perforation in one layer with big bites laparoscopically. Are you perhaps suggesting that we open in order to wash out the abdomen?

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A Doctor

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#5 »

I think oversewing the hole is perfectly adequate--I don't understand why you would entertain all these other complex options that you would never consider anywhere else in the bowel.

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Billroth

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#6 »

What would you do if this was an open op to start with? Close the hole? Then do the same thing. If you are not confident at lap suturing, then convert to do so. Whichever way, use a drain (not suction which can block) as a guide to how successful you have been.

Laparoscopy is only a means of access, not a different operation.

A few years ago I had a bile leak after lap chole. I was convinced that there was no possibility of CBD damage, and treated expectantly, i.e. left in the suction drain that I usually use for up to 24 hours. After 10 days there was no improvement, so went for ERCP. This showed the CBD to be fine, but there was a small duodenal perforation. I treated this conservatively as well, and eventually all healed but not before the drain site necrosed and one and a half kilos of dead fat sloughed. I think I was lucky, and would go for closure of the perf next time. I reviewed the video and am certain that this was NOT due to a cholecystoduodenal fistula, but to a diathermy injury - cant prove it though.

Chirurgia

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#7 »

A minus duodenal perforation took place during lap chole...Was it a preexistent cholecistoduodenal fistulae of very small size or was it a iatrogenic one?..I incline myself to think that it was the second. This one was unnoticed and leaked very small amounts of contents...Yet,some symptoms and signs appeared that made rescope the pt.

You has named all the possible attitudes that one can take in front of such a problem and as he asks for opinions,I should say that I would have tryied some stitches and omentopexy + aspiration of leaked fluids if the small hole was visible...No drainage...Only NG tube for gastric aspiration for a couple of days.

If the hole was not visible and there was bile content present in the cavity,I would have converted to open lap thru a very small incision and then suture ,omentopexy,no drain and closure.

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Surgeon

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#8 »

Because I cannot define the perforation and repair it laparoscopically- no skills. This is a life threatening complication- I would like to deal with it the best I can- for me this means a conversion.

> Are you perhaps suggesting that we open in order to wash out the abdomen?

No. There is no need to wash the abdomen. If you want to wash you can do it also laparoscopically.

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Sweden surgeon

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#9 »

This is a follow-up on my patient with duodenal perforation following lap chole. Upon insertion of the camera, there was some brown fluid in the abdomen, particularly along the right gutter. At first, we could not identify the perforation, but after filling the stomach with methylene blue, a small trickle of blue dye could be seen coming from a 1-2 mm hole just distal to the duodenal bulb. The mucusa did not mushroom out side.

It was faily easy to close the hole with two sutures. I did butress the suture line with a bit of omentum. Sucked all the fluid out, with a bit of irrigation, and left a JP drain in Morrisson' pouch.

Patient took a few days to recover, and developed a wound infection in the operating port site. I use Hasson technique for the umbilical port, and put the operating port through the left rectus. Consequently, the umbilical port is closed with sutures, but the operating post with skin staples alone. The umbilical port remained clean, but the operating port got infected. Perhaps I should have closed the fascia on the operating port as well.

Scalpel

Re: Duodenal perforation during lap Chole - Ärzteforum

Post#10 »

I close the fascia of all 10 mm and larger incisions but I don't see how this would have affected whether the incision got infected. If there was infected fluid inside the abdomen that needed a route out through this incision, it should be better that it drained through the incision than stayed inside the abdomen.

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