Management of Bile Leak Post Minimally Invasive Subtotal Cholecystectomy: A Review

Minimally invasive subtotal cholecystectomy (STC) is a safe alternative to minimally invasive cholecystectomy that prevents bile duct injury. Nonetheless, it is associated with higher rates of other complications, namely postoperative bile leak and symptomatic remnant cholelithiasis.

Bile leak presents as biloma requiring drainage and subsequently high bilious drain output. It is more strongly associated with fenestrating STC. Fortunately, the majority are self-limited and do not require endoscopic intervention. Symptomatic remnant cholelithiasis presents as recurrent gallstone disease postoperative cholecystectomy.

In this paper, we review available literature on these 2 complications and share our institutional algorithm on the management of bile leak.

Our approach to bile leak advocates for intraoperative drain placement, early characterization of the leak, watchful waiting, the use of sinogram, and reserving endoscopic retrograde cholangiopancreatography and stenting for high-grade leaks or refractory cases. Symptomatic remnant cholelithiasis is more strongly associated with reconstituting STC, particularly in cases where the gallbladder stump is long or stones are not completely evacuated from the remnant. This complication should be treated with complete cholecystectomy when possible, but can also be managed with gallbladder-preserving cholecystolithomy in patients with aberrant biliary anatomy and/or significant comorbidities. Completion cholecystectomy is a technically challenging operation that benefits from hepatopancreaticbiliary expertise and intraoperative adjuncts such as near-infrared fluorescent cholangiography or intraoperative cholangiogram.

Minimally invasive STC effectively prevents bile duct injury but at the expense of increased postoperative morbidity; it is a bailout strategy that should be used judiciously.