Biliary Tract Injuries and Complications

A 42-year-old woman undergoes elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Intraoperatively, there is significant bleeding from the hepatic bed, and the surgeon converts to open surgery. During dissection, the common bile duct (CBD) is inadvertently transected. The injury is recognized immediately. The patient's vitals are stable. What is the most appropriate immediate management?

A 38-year-old man presents to the emergency department 5 days after an uncomplicated open cholecystectomy performed at a peripheral hospital. He complains of right upper quadrant pain, fever (38.5°C), and jaundice. Examination reveals right upper quadrant tenderness and hepatomegaly. Laboratory values: total bilirubin 4.2 mg/dL, direct bilirubin 3.8 mg/dL, ALT 320 U/L, AST 280 U/L, ALP 180 U/L. Abdominal ultrasound shows a 4 cm hypoechoic collection in the hepatic bed with mild intrahepatic biliary dilatation. What is the most likely diagnosis and the next step in management?

Which of the following is the most common site of bile duct injury during laparoscopic cholecystectomy?

A 42-year-old woman undergoes elective laparoscopic cholecystectomy for symptomatic gallstones. Intraoperatively, the surgeon encounters dense adhesions and converts to open surgery. On postoperative day 3, she develops fever (38.5°C), right upper quadrant pain, and jaundice. Serum bilirubin is 4.2 mg/dL (direct 3.1 mg/dL), ALT 320 U/L, and ALP 180 U/L. Abdominal ultrasound shows dilated intrahepatic bile ducts and a small fluid collection near the hepatic hilum. What is the most likely diagnosis?

A 38-year-old man undergoes laparoscopic cholecystectomy for acute cholecystitis. Intraoperatively, the cystic artery is ligated, but the surgeon notes a small perforation of the gallbladder fundus with bile spillage. The perforation is irrigated and the gallbladder is carefully removed. On postoperative day 5, the patient develops fever (39.2°C), right upper quadrant tenderness, and mild jaundice. CT abdomen shows a 4 cm loculated fluid collection in the hepatic bed with gas within it. Blood cultures grow E. coli. What is the most appropriate next step in management?