Case Report

Emergency Liver Resection for Combined Biliary and Vascular Injury Following Laparoscopic Cholecystectomy: Case Report and Review of the Literature

Authors: Evangelos Felekouras, MD, Thomas Megas, MD, Othon P. Michail, MD, Ioannis Papaconstantinou, MD, Nikolaos Nikiteas, MD, Dimitrios Dimitroulis, MD, John Griniatsos, MD, Anastasios Tsechpenakis, MD, Gregorios Kouraklis, MD

Abstract

A 75-year-old woman suffering from symptomatic cholelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflammation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed.


Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting.


Key Points


* Combined biliary, hepatic artery and portal vein injury at the level of porta hepatis can occur following laparoscopic cholecystectomy.


* Liver resection in the acute setting (20 h after laparoscopic cholecystectomy) can be safely performed.

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References

1. McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic versus minilaparotomy cholecystectomy: a randomised trial. Lancet 1994;343:135–138.
 
2. Diamantis T, Tsigris C, Kiriakopoulos A, et al. Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute. Surg Today 2005;35:841–845.
 
3. Alves A, Farges O, Nicolet J, et al. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg 2003;238:93–96.
 
4. Madariaga JR, Dodson SF, Selby R, et al. Corrective treatment and anatomic considerations for laparoscopic cholecystectomy injuries. J Am Coll Surg 1994;179:321–325.
 
5. Robertson AJ, Rela M, Karani J, et al. Laparoscopic cholecystectomy injury: an unusual indication for liver transplantation. Transpl Int 1998;11:449–451.
 
6. Frilling A, Li J, Weber F, et al. Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience. J Gastrointest Surg 2004;8:679–685.
 
7. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 1992;215:196–202.
 
8. Nishio H, Kamiya J, Nagino M, et al. Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg1999;6:427–430.
 
9. Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005;12:351–355.
 
10. Perini RF, Uflacker R, Cunningham JT, et al. Isolated right segmental hepatic duct injury following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 2005;28:185–195.
 
11. Schmidt SC, Langrehr JM, Raakow R, et al. Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbecks Arch Surg 2002;387:183–187.
 
12. Stewart L, Robinson TN, Lee CM, et al. Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences. J Gastrointest Surg 2004;8:523–530; discussion 530–521.
 
13. Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003;237:460–469.
 
14. Scott-Conner CE, Hall TJ. Variant arterial anatomy in laparoscopic cholecystectomy. Am J Surg 1992;163:590–592.
 
15. Mays ET, Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med 1974;290:993–996.
 
16. Gupta N, Solomon H, Fairchild R, et al. Management and outcome of patients with combined bile duct and hepatic artery injuries. Arch Surg 1998;133:176–181.
 
17. Koffron A, Ferrario M, Parsons W, et al. Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 2001;130:722–728; discussion 728–731.
 
18. Uenishi T, Hirohashi K, Tanaka H, et al. Right hepatic lobectomy for recurrent cholangitis after bile duct and hepatic artery injury during laparoscopic cholecystectomy: report of a case.Hepatogastroenterology 1999;46:2296–2298.
 
19. Kayaalp C, Nessar G, Kaman S, et al. Right liver necrosis: complication of laparoscopic cholecystectomy. Hepatogastroenterology 2001;48:1727–1729.
 
20. Sekido H, Matsuo K, Morioka D, et al. Surgical strategy for the management of biliary injury in laparoscopic cholecystectomy. Hepatogastroenterology 2004;51:357–361.
 
21. Soderlund C, Frozanpor F, Linder S. Bile duct injuries at laparoscopic cholecystectomy: a single-institution prospective study: acute cholecystitis indicates an increased risk. World J Surg 2005;29:987–993.
 
22. Slater K, Strong RW, Wall DR, et al. Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy. ANZ J Surg 2002;72:83–88.
 
23. Heinrich S, Seifert H, Krahenbuhl L, et al. Right hemihepatectomy for bile duct injury following laparoscopic cholecystectomy. Surg Endosc 2003;17:1494–1495.
 
24. Mercado MA, Chan C, Orozco H, et al. Bile duct reconstruction after iatrogenic injury in the elderly. Ann Hepatol 2004;3:160–162.
 
25. Kaman L, Behera A, Singh R, et al. Management of major bile duct injuries after laparoscopic cholecystectomy. Surg Endosc 2004;18:1196–1199.
 
26. Johnson SR, Koehler A, Pennington LK, et al. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 2000;128:668–677.