Fig. 4

Surgical procedures. A Trocar positioning for laparoscopic surgery. Three ports with a camera port were initiated (red lines) and a subcostal port was added intraoperatively (blue line). B Inflammation persisted around the gallbladder. C We explored the location of the duodenal fistula under endoscopic guidance. D Indigo carmine from the PTGBD tube flowed out to the site of the fistula opening (arrow). E The fistula led to the hepatoduodenal ligament. F Cholecystectomy was performed using the dome-down approach, and the cystic duct was tightened with an Endoloop^®. G Fistula closure at the duodenal side was performed with the running suture technique using V-Loc™. GB: gallbladder, Du: duodenum, HDL: hepatoduodenal ligament