VS 04 - HPB Laparoscopic trans-vesical approach is safe management for cholecystoduodenal fistula

Abstract Background A 71 year old female initially presented cholangitis. Her MRCP showed a distal common bile duct (CBD) stone. An ERCP was then performed which was not successful due to anatomical challenge in the form of a large diaphragmatic hernia. An elective laparoscopic cholecystectomy with IOC was performed. An incidental cholecystoduodenal fistula was found therefore the clinical decision was made to perform a trans-vesical approach to fistulogram. This showed a fistula was present and that it was not complicated further. This case shows that this approach avoided iatrogenic injury by confirming presence of the fistula and aided further surgical planning. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. The duodenum was adherent to the gallbladder body therefore a trans-vesical enterotomy was performed. Fistulogram confirmed presence of a cholecystoduodenal fistula but nil further pathology. The fistula was dissected from the gallbladder and stapled with the GIA endo- tri-staple 45 Purple. Further dissection to gallbladder to ensure clear visualisation of calot’s triangle. Basket trawl of the CBD was performed and repeat cholangiogram was clear. The gallbladder was dissected from gallbladder fossa, all gallstones were removed and 3L of wash was used to irrigate the intra-abdominal cavity. Results The patient was admitted following the procedure and was discharged on day two with PPI. She was reviewed post-operatively at 12 weeks and had no further issues. She remains well and has had no further episodes of cholangitis or hospital admissions in almost four years since the procedure. Conclusion This case shows an unexpected finding of cholecystoduodenal fistula in a planned laparoscopic cholecystectomy with IOC. It is important to note that some gas was seen in the gallbladder on initial imaging therefore indicating a possible cholecystoduodenal fistula. This trans-vesical approach with fistulogram confirmed a simple fistula and no further pathology and aided safe surgical planning. This improved patient outcomes and avoided iatrogenic injury thus providing a safer way to manage cholecystoenteric fistula. This novel approach to cholecystoduodenal fistula repair improves patient safety, length of stay and by aiding intra-operative planning and avoiding iatrogenic injury.