Postlaparoscopic cholecystectomy biloma in the lesser sac: A rare clinical presentation.

Bilomas resulting as a complication of cholecystectomy are often due to a leak from an inadequately secured cystic duct stump, an accessory bile duct or a duct of Luschka in the gallbladder fossa of the liver. Occasionally, bilomas may have an unusual presentation. We describe here a rare case of biloma in the lesser sac after an uneventful laparoscopic cholecystectomy.

INTRODUCTION

Laparoscopic cholecystectomy (LC) has dramatically altered the management of patients with cholelithiasis. However, compared with open cholecystectomy, the incidence of bile duct injury appears to be increased, resulting in significant morbidity.[1]

Bile duct injury during LC ranges from mild to severe with serious and disastrous consequences. Bile leak after LC is known to occur in 0.2-2% of patients. It may lead to fistula formation or life-threatening biliary peritonitis in case of a significant leak.

In case of small leaks, it could be entrenched by the adjacent organs and fibrin usually forming a localized collection or biloma.[2] Bilomas are often due to a leak from an inadequately secured cystic duct stump, an accessory bile duct or a duct of Luschka in the gallbladder fossa of the liver.

Biloma have been reported to have occurred at unusual locations such as in the abdominal wall or even intrahepatic sub-capsular space.[34]

We report a case of biloma presenting at an unusual location in the lesser sac. This report adds one more unusual presentation of biloma.

CASE REPORT

A 28-year-old previously healthy female presented to the Outpatient Department 10 days following LC. The patient complained of moderate pain in epigastrium and right hypochondrium starting 2 days after the operation. Pain radiated to the back. She had no fever and no jaundice and her medical history did not suggest any major comorbid condition. Her discharge reported an uneventful LC. The physical examination revealed the patient to be average built, conscious, and oriented; she was afebrile with pulse rate of 76 beats/min and blood pressure of 100/70 mm Hg.

Her abdominal examination revealed healed port site scars, a soft abdomen with no signs of peritonitis. There was a vague mass palpable in the epigastrium and left hypochondrium, tender on deep palpation. Laboratory data revealed a haemoglobin of 10.9 g/dl, white blood cells of 10,700/mm3(83% neutrophils), a blood urea of 40 g/l, and a creatinine level of 1 mg/l. Liver enzymes showed a total bilirubin of 1 mg/l with a direct component of 0.4 mg/l; serum glutamate-oxaloacetate transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase were 70 IU/l, 60 IU/l and 46 IU/l respectively. Serum amylase level were 48 U/l, ultrasonography of the abdomen revealed a large unilocular fluid-filled collection in the left hypochondrium.

A diagnosis of postoperative LC subhepatic collection was made and patient posted for diagnostic laparoscopy.

Diagnostic laparoscopy revealed a prominent bulge of stomach [Figure 1] with stretching of the gastrocolic omentum due to a collection in the lesser sac; the gall bladder fossa and surrounding organs were unremarkable [Figure 2]. Bulge appeared to be a psuedocyst; however, there were no other intra-abdominal signs of pancreatitis. In view of no positive history suggestive of pancreatitis the decision to access the cyst was made. The gastro colic ligament was divided and a clear bilious fluid [Figure 3] was seen in the lesser sac. A litre of this fluid was drained from the lesser sac and an abdominal drain left in place. There was no intraoperative adverse event. The patient had an uneventful postoperative period with no further bilious drainage in the drain. The drain was removed after 7 days of surgery. The patient is free of any symptoms until date.

Figure 1

Diagnostic laparoscopy revealing prominent stomach bulge

Figure 2

Unremarkable subhepatic area

Figure 3

Lesser sac showing bile collection

DISCUSSION

Bilomas resulting as a complication of cholecystectomy are often due to a leak from an inadequately secured cystic duct stump, an accessory bile duct or a duct of Luschka in the gallbladder fossa of the liver.

Bilomas usually present with abdominal pain, nausea, anorexia, jaundice, fever and abdominal tenderness, but presentation may vary from minimal symptoms to full blown biliary peritonitis.

Biloma management may vary from percutaneous catheter drainage to overt surgical treatment. If the leak is small, it will resolve spontaneously in few days.[2]

Our patient presented with unusual features for a biloma, which included an unlikely site of bile collection following an uneventful LC. Patient was managed with diagnostic laparoscopy and drainage. On follow-up, patient was subjected to a magnetic resonance cholangiopancreatography, which showed normal biliary anatomy.

Literature review shows only one report of such presentation.[5]

CONCLUSION

Bilomas must be considered in the differential diagnoses of postoperative patient presenting with unusual clinical presentation after an uneventful LC.