Old is still gold.

Common bile duct injury is infrequent but a serious complication of cholecystectomy. Variable biliary anatomy has an increased risk of iatrogenic injury. Intraoperative cholangiogram can be performed to provide a clearer picture of biliary anatomy. We report a case of a 71-year-old lady who underwent cholecystectomy for symptomatic gallstones. Anatomy initially was misinterpreted at laparoscopy when common bile duct was identified as a cystic duct, and a hole in what appeared to be Hartmann's pouch was in fact in common hepatic duct. If continued laparoscopically, further misconception could have led to the complete excision of the biliary system. Instead, procedure was converted to an open and intraoperative cholangiogram performed, which confirmed a diagnosis of Mirizzi syndrome. Following the identification of structures, subtotal cholecystectomy was completed. The patient made an uneventful recovery. This case highlights the limitations of laparoscopy and the importance of an intraoperative cholangiogram. Despite advances in surgical techniques, we continue to advocate a low threshold for its use during cholecystectomy as a useful tool in evaluating and minimising the extent of biliary injury.

Is live problem better than dead cert?

Cholecystoduodenal fistula is a type of biliary enteric fistula that can occur as a result of chronic cholecystitis. The majority of cases are diagnosed and their subsequent management planned intraoperatively. Previous reports have focused on successful laparoscopic management. We report three cases of elective cholecystectomy that were diagnosed intraoperatively with a cholecystoduodenal fistula (CDF). The first two cases were managed laparoscopically. In case 3 further continuation of surgery would have subjected the patient to significant risk of further harm. Instead the patient underwent cholecyststomy with insertion of Foley's catheter and venting gastrostomy. All three patients made a full recovery postoperatively. CDF can be of varying severity. Our third case highlights the use of damage limitation surgery when carrying on is at risk of harm. Treatment therefore needs to be tailor made for each fistula identified.