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Damage to hepatic ducts

01 February 2004

Dr E, a specialist in general surgery, performed a laparoscopic cholecystectomy on Ms N.

Postoperative liver function tests showed moderately elevated transaminases and alkaline phosphatase, normal bilirubin and WBC. An ultrasound of the liver and gall bladder revealed no abnormality, and Ms N was discharged home.

About two weeks after the operation, Ms N started to experience a dull ache in her back; this was followed by pain in the epigastrium and the right upper quadrant of the abdomen.

She was re-admitted to hospital where investigations showed a large fluid collection in the sub-hepatic region. A drain was inserted, which produced a daily yield of between 200ml and 300ml of bile-stained fluid.

Ms N was referred to a specialist in hepatic surgery; he performed a laparotomy and identified the source of the bile leakage as the right anterior and posterior hepatic ducts, which were divided.

He opened the common bile duct and, ascertaining via a T-tube cholangiogram that the left hepatic duct was intact, carried out a hepatico-jejunostomy to the right anterior and posterior hepatic ducts.

Four months passed. Ms N was re-admitted with a four-day history of acute abdominal pain. The cause was identified as an intestinal obstruction, which required surgery.

An internal herniation of the proximal small bowel at the jejunostomy site was causing compression of the jejunum. The herniation was reduced and the defect was repaired. Ms N made a good recovery and this last operation seemed to resolve her problems.

Ms N asked Dr E to compensate her for pain and suffering and the loss of her job.

We asked an expert in general surgery working in the same country for his opinion. On the basis of his advice, we agreed to pay Ms N the compensation.

Learning points

The expert was critical of Dr E for:

  • not warning Ms N about the risks of cholecystectomy and the relative risks and benefits of laparoscopic and open surgery;
  • not taking adequate precautions to guard against bile duct injury – ‘By simply freeing the cystic duct [without first clearing the soft tissue to expose the junction between the cystic duct and Hartmann’s pouch] there is always a possibility that the common duct could be mistaken for the cystic duct’;
  • undue delay in diagnosing the complication – if he had examined the resected specimen after the operation, he would have realised his error.