Cystic Duct Leaks After Laparoendoscopic Single-Site Cholecystectomy Journal
of Laparoendoscopic & Advanced Surgical Techniques

> Rajeev Sinha and Sharad Chandra. Journal of Laparoendoscopic & Advanced
> Surgical Techniques. Ahead of print. doi:10.1089/lap.2012.0094.
Author information
> Rajeev Sinha, MS, FICS, FAIS, and Sharad Chandra, MD, DM
Department of Surgery, M.L.B. Medical College, Jhansi, Uttar Pradesh,
> India.

 *Abstract*

> *Background:* Leakage from the clipped cystic duct stump (cystic duct
stump leak [CDSL]) as a cause of biliary peritonitis has not been
emphasized enough. It deserves special mention because it is not an
uncommon cause and it is easier to treat. With the advent of
laparoendoscopic single-site (LESS) cholecystectomy, its occurrence in
relation to other causes of biliary peritonitis needs reexamination.

> *Subjects and Methods:* Details of 756 patients undergoing LESS
cholecystectomy were analyzed, and patients presenting with biliary
peritonitis were identified. The investigative profile included an
ultrasound, contrast-enhanced computed tomography scan, and endoscopic
retrograde cholangiopancreatography (ERCP) to identify the site of leak.
The management in addition to stenting included abdominal tube drainage.

> *Results:* There were 5 (0.66%) patients, all female, with biliary
peritonitis, and 4 of them (0.53%) had cystic stump leakage as identified
by ERCP. The usual time of presentation was in the first week after
surgery, with acute abdominal pain and vomiting. Common bile duct stenting
was carried out, after choledocholithotomy where required, at the same ERCP
session. Tube abdominal drain was required in 2 patients, and 1 patient had
to undergo exploratory laparotomy for an associated acute intestinal
obstruction. All the patients recovered completely. The stent was removed
between 4 and 6 weeks after ERCP.

> *Conclusions:* Effective CDSL management requires early recognition and
management. ERCP is the cornerstone for correct identification, and common
bile duct stenting was curative in all patients.


> This paper that shows an increse in leakage from failed placement of the cystic duct clip.


Comentário: Não há dúvida que o clip é menos seguro que a ligadura com fio do ducto cístico. No entanto, o mais importante é o cuidado técnico. O clip só funciona se o ducto cístico for adequadamente dissecado, o clip bem postado, enxergando-se a ponta do clipador. O clipador deve ser o adequado ao tipo específico do clip, o qual, é claro, deve ser de tamanho adequado a estrutura. Por fim, o clip deve ter ranhuras para que se estabeleça melhor no ducto. Já a ligadura com fio, deve ser bem feita seja com nó externo ou interno com a correta confecção do nó. Por não necessitar de um trocarter de 10 mm, a ligadura com fio pode ser feita através de portal de 5 ou 3 mm, o que também é uma vantagem.
Especificamente neste artigo, o portal único é fator claro de prejuízo técnico causador da complicação.
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