Novel use of cholangioscopy for restoration of a completely transected bile duct after a failed surgical revision. Iatrogenic bile duct injury is the most serious complication of laparoscopic cholestectomy resulting in a significant impact on quality of life and overall survival. Early recognition of the complication is paramount and along with location of the injury will dictate type of appropriate management. Endoscopic treatment with or without rendezvous technique can be utilized for most cases. However, a complete transection of the bile duct is the most serious and usually requires a surgical revision with hepatical jejunostomy. 33-year-old female was admitted with gangrenous cholecystitis and laparoscopic cholestectomy was performed. Intraoperative cholangiogram showed a bile leak from the liver bed and drains were placed. ERCP showed injury at the bifurcation to the right hepatic duct but a guide wire could not be passed across and a stent could not be placed. Patient was taken for Roux-en-Y hepatical jejunostomy which was complicated by bleeding at the anastomosis requiring a coil embolization. Subsequently, an asthmatic dehiscence with a large volume bile leak occurred. Further surgical options were felt to be limited and patient was transferred for endoscopic management. ERCP was performed and cholangiogram showed a competent stump of the common bile duct. This was punctured across using a three french tip cannula. Next, a guide wire was passed across the staples and the tract was dilated using a four millimeter dilation balloon. Contrast injection or blind cannulation attempts to access the intrahepatic ducts were not successful. Use of different angled guide wires or use of sphincter tomes to further aid in angulation of the guide wire did not work. Next, the cholangioscope was passed into the bile duct and was manipulated across the staple line into the peritoneum at the hepatic hilum. Once across the staple line, both clangoscopic images as well as fluoroscopic images were used to find the opening into the common hepatic duct. Once the cholangioscope was in the disconnected bile duct, contrast injection was done and confirmed the correct position. Next, a guide wire was passed deep into the left hepatic duct and the cholangioscope was removed over the wire. Due to prior surgeries, a sharp sigmoid angulation of the bile duct was noted. To decrease stent migration, a straight 7 French plastic biliary stent was modified into a sigmoid shape using hot and cold water before placing into the bile duct. After the bioduct stent was successfully placed, the bioleak significantly improved and the external drain was eventually removed after several weeks. Over the next one year, a patient was brought back for plastic stent upsizing and exchanges with eventual removal of all stents. No further surgery was needed. Referral to a tertiary center with experience in both surgical and endoscopic management of bioduct injury is recommended. Use of cholangioscopy to aid in treatment of iatrogenic bioduct injury should be considered if other techniques fail, reducing the need for additional surgery and liver transplantation.

cholangioscopy

bile duct restoration

iatrogenic bile duct injury

laparoscopic cholecystectomy

endoscopic treatment