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Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India

Case of the Month

< Case No. 69 : January 2026 >

Double Trouble - Incarcerated Hernia causing Obstructive Jaundice:

Contributed by : Rushabh Shirish Mehta

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Introduction :

Laparoscopic cholecystectomy, while a standard management for cholelithiasis, can be complicated by major biliary injuries leading to bile leak and common bile duct (CBD) strictures. The preferred surgical management of iatrogenic CBD strictures is Roux-en-Y hepaticojejunostomy. A rare but serious late complication of this procedure is the incarceration of the biliary limb through an incisional hernia, leading to mechanical small bowel obstruction and subsequent obstructive jaundice. This case illustrates the imaging findings and clinical presentation of this uncommon cause of biliary obstruction.

Clinical Profile:

A 42-year-old woman presented with abdominal pain and an irreducible right lumbar swelling at a previous surgical scar site. She had a history of CBD injury during laparoscopic cholecystectomy, managed by Roux-en-Y hepaticojejunostomy. Laboratory evaluation revealed hyperbilirubinemia with elevated direct bilirubin, indicating obstructive jaundice.

Radiological findings

Ultrasonography

The initial ultrasonography of the abdomen revealed herniated bowel loops with a dilated proximal loop measuring ~3.6 cm in diameter, suggestive of obstruction (Figure 1). The dilated bowel loop was traced to the porta hepatis, where a dilated CBD was seen opening into the jejunal limb (Figure 2), confirming the anatomy of the hepaticojejunostomy and the level of obstruction.

Fig 1 Ultrasonography of the abdomen shows herniated bowel loops (white arrow) with a dilated proximal bowel loop with a diameter of 3.6 cm

Fig 2 The ultrasonogram shows the common hepatic duct to be dilated upto 7.4mm (Black arrow) opening into the jejunal loop that forms the biliary limb of hepaticojejunostomy (arrowhead)

Contrast-Enhanced CT Abdomen and pelvis

The coronal and sagittal images of contrast-enhanced CT scan of the abdomen revealed a right abdominal wall hernia at the prior surgical scar site (Figure 3a and 3b). The afferent (biliary) limb of the Roux-en-Y hepaticojejunostomy was herniated, creating a transition point and causing small bowel obstruction with upstream biliary dilatation. The herniated bowel loop showed normal mural enhancement, a key feature differentiating incarceration from strangulation (Figure 3c and 3d). Axial sections demonstrated a narrow-neck hernia.

Fig 3a and 3b The coronal and sagittal contrast-enhanced CT scan of the abdomen show a defect in the right lumbar region with herniation of the jejunal loop forming the biliary limb of hepatico-jejunostomy. The proximal loop is dilated (white arrow) with an abrupt transition point (white asterisk) at the hernial site with the herniated loops showing enhancement (arrow). There is dilatation of the intrahepatic biliary radicles (black arrow).

Figure 3c and 3d. Axial sections of the contrast-enhanced CT scan show a narrow necked hernia with a herniated bowel loop showing mural enhancement, as shown by a difference of about 30 HU between the non-contrast and contrast-enhanced phases.

MR Cholangiography

Axial T2 HASTE images showed dilated intrahepatic biliary radicles (Figure 4). The MIP reconstruction of the MR cholangiogram clearly demonstrated the markedly dilated, fluid-filled proximal jejunal loop arising from the hepaticojejunostomy site. Due to obstruction and fluid stasis, this bowel loop appeared hyperintense on heavily T2-weighted sequences, alongside the dilated intrahepatic bile ducts (Figure 5).

Figure 4. The axial section of the T2 HASTE sequence of MR cholangiography shows dilated intrahepatic biliary radicles (black arrows).

Figure 5. (right) The MIP image of the MR cholangiogram shows an obstructed jejunal loop giving high intensity signals (white arrow) upstream dilatation of intrahepatic biliary radicles

Radiological diagnosis:

Post laparoscopic cholecystectomy related Incisional hernia, biliary obstruction

Management:

Surgical reduction of the incisional hernia was performed. Intraoperative images show congested herniated bowel loops at the right lumbar region.

Figure 6. Intraoperative mage shows the herniated bowel loops through a narrow defect (Black arrow). The Bowel loops are congested (white arrow).

Timeline:

Discussion

An external hernia is a common cause of small bowel obstruction, often occurring at sites of previous surgery. In this case, the presence of an irreducible swelling at the surgical site was indicative of an incarcerated incisional hernia, a surgical emergency. The unique aspect here was the herniation of the biliary limb of a hepaticojejunostomy. This created a dual obstruction: a mechanical small bowel obstruction with obstruction of the biliary drainage pathway, leading to obstructive jaundice.

The pathophysiology of this dual obstruction hinges on the unique post-surgical anatomy. The afferent (biliary) Roux limb serves as the sole conduit for biliary drainage. Its herniation and incarceration create a closed-loop obstruction, leading to back-pressure within the intrahepatic ducts and acute obstructive jaundice [1, 2].

In such complex presentations, differentiating this entity from other causes of postoperative biliary obstruction, such as anastomotic stricture or recurrent choledocholithiasis, is critical for appropriate management [1, 2]. The constellation of imaging findings—specifically the herniated bowel limb connected to the biliary tree—is pathognomonic. Ultrasonography serves as a valuable first-line modality for identifying the hernia and dilated bowel and biliary systems [3, 4]. However, contrast-enhanced CT is the investigation of choice, as it precisely identifies the transition point, confirms the hernia as the cause, and critically assesses bowel wall enhancement to rule out strangulation [5, 6].

MR Cholangiography is an excellent for non-invasively outlining biliary anatomy and, in this specific scenario, visualizing the obstructed, fluid-filled biliary limb due to the T2 hyperintensity of static fluid [7]. It also effectively rules out other intra-luminal or mural causes of obstruction in the excluded limb [7, 4].

From a management perspective, cross-sectional imaging is indispensable for surgical planning. Defining the hernia's neck, the viability of the herniated bowel, and the precise anatomy of the Roux limb prevents intraoperative surprises and guides the choice between simple reduction and possible resection [5, 6]. Timely intervention is of paramount to prevent progression to strangulation or severe cholestasis.

The surgical approach requires careful consideration of the prior biliary reconstruction. While open hernioplasty was successful here, the integrity of the hepaticojejunostomy anastomosis must be preserved during reduction to avoid a catastrophic leak. Adhesiolysis can be challenging, and preoperative imaging helps anticipate these difficulties [2].

This case underscores the need for long-term follow-up in patients after complex biliary surgery. Patient education on recognizing signs of hernia and jaundice is crucial. Furthermore, it highlights a potential argument for prophylactic mesh repair during the initial hepaticojejunostomy in select high-risk patients to prevent this serious late complication, although this must be balanced against mesh-related risks like infection or erosion [6].

Ultimately, this rare complication serves as an important reminder of the altered anatomy created by reconstructive surgery. It reinforces the principle that in a patient with a history of Roux-en-Y hepaticojejunostomy, a new abdominal wall hernia should never be dismissed as a benign finding, as it can directly threaten the patency of the biliary-enteric conduit.

Conclusion :

This case highlights an uncommon etiology of obstructive jaundice: incarceration of the biliary limb following Roux-en-Y hepaticojejunostomy. A high index of suspicion is needed in patients with prior biliary surgery presenting with an abdominal wall hernia and jaundice. Cross-sectional imaging, particularly CT, is crucial for diagnosis, preoperative planning, and assessing bowel viability. Prompt surgical intervention, as performed in this case with open hernioplasty, leads to the resolution of both bowel obstruction and jaundice.

References:

1. Radunovic M, et al. Complications of laparoscopic cholecystectomy: our experience from a retrospective analysis. Open Access Maced J Med Sci. 2016.

2. Kukar M, Wilkinson N. Surgical management of bile duct strictures. Indian J Surg. 2015.

3. Hefny AF, Corr P, Abu-Zidan FM. The role of ultrasound in the management of intestinal obstruction. J Emerg Trauma Shock. 2012.

4. Gupta P, Gupta J, Kumar-M P. Imaging in obstructive jaundice. J Clin Interv Radiol ISVIR. 2020.

5. Silva AC, Pimenta M, Guimarães LS. Small bowel obstruction: what to look for. Radiographics. 2009.

6. Aguirre, D. A., Santosa, A. C., Casola, G., & Sirlin, C. B. Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT. Radiographics. 2005.

7. Katabathina VS, Dasyam AK, Dasyam N, Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics. 2014.

Acknowledgement:

We are grateful to the Department of Surgery for povidinf th intraopertive imges

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