Accidental ligation of the hepatic artery. Report of one case, with a review of the cases in the literature

Abstract

ACCIDENTAL ligation of the hcpatic artery is fortunately rare. Twenty-seven cases have been reported in the literature up to datc. The rarity of the lesion and the complete investigation carried out prompts the presentation of this report. CASE REPORT.W. W., male, age 49, was admitted to Dr. R. R . Graham's service of the Toronto General Hospital on Kov. 5 , 1930, with a right inguinal hernia, haemorrhoids, and a slight prolapse of the rectum. During the course of routine history and physical examination, a pyloric carcinoma was diagnosed and confirnicd by radiological examination. Accordingly on Nov. 12, 1930, following the usual pre-operative preparation, a partial gastrectomy was done.A moderately extensive pyloric carcinoma was found, with enlarged lymphglands extending upward into the gastro-hepatic omentum and along the lesser curvature of the stomach, almost t o the msophagus ; glandular enlargement in the gastrocolic omcntuni was not extensive. There was marked inflammatory reaction and induration of the gastro-hepatic ornentum which extended along the anterior border of the foramen of Winslow. The pylorus was freed after division of the gastrocolic omentum. The vessels along the superior border of the pylorus were isolated, divided, and ligated. During this procedure a large vessel which was enmeshed in inflammatory adhesions was divided and tied. It was immediately thought that the hepat,ic artery had been severed. Subsequently more careful examination following the closrire of the duodenal stump confirmed this belief. Approximately one inch of thc hepatic artery had been removed a t a point about one and a quarter inches from its origin in the coeliac axis. The operation was completed in the usual manner, a posterior end-to-side retrocolic gastrojejunal anastomosis being done. No changes were noted in the liver during the operation. The abdomen was closed in layers without drainage, and the patient returned t,o the ward in good condition. Post-operatively continuous intravenous saline was given by the drop method, supplemented with the usual sedatives. Blood-sugar (F~ig. 343) and non-protein nitrogen estimation (Fig. 344) were done hourly for the first four hours and at greater intervals thereafter. These showed no marked variation from the normal. The Van den Bergh reactions were negative throughout, and small quantities of urobilin were detected in the urine only the day preceding death.Clinically the patient progressed favourably for the first three days. The evening of the fourth day his temperature rose to 10.7" F. with a simultaneous elevation in pulse and respirations. Bilateral bronchopneumonia was diagnosed. He became rapidly worse and died on the seventh day of pneumonia, cardiac failure, and terminal pulmonary edema.Post-mortem examination revealrd extensive bilateral bronchopneumonia of * From tlir Ikpartment of Surgery and rkpartment of l'ntliology, I'nivrrsity of Toronto.

Determination of the Hepatic Arterial Blood Flow and Oxygen Supply in Man by Clamping the Hepatic Artery During Surgery

“…If, however, under certain conditions the oxygen requirements of the liver rise, or the oxygen saturation of the portal venous blood falls owing to an increased mesenteric oxygen consumption [e.g., during absorption (27) It is not possible from the present study to evaluate the late sequelae of ligation of the hepatic artery in man. The great individual variation in hepatic arterial blood flow found in our patients may, however, explain why the artery in some cases may be ligated without noticeable influence on the liver (34), while in other cases it is fatal (8). In the present short-term experiments the clamping of the hepatic artery in all cases seemed to be harmless.…”

“…Great differences have been found from one species to another (6,7), and our knowledge of the significance of the arterial blood supply to the human liver is limited mainly to observations of the late effect of occlusion of the hepatic artery (8) or of the portal vein (9,10). As these events are followed by compensatory changes in the hepatic circulation (11,12), no definite conclusions regarding the physiological role of the hepatic artery can be made on this basis.…”

Bedeutung der Arterialisation des Transplantates bei Rattenlebertransplantation

“…Bei der Ausschaltung der arteriellen Blutzufuhr steigt die hepatische Extraktion des Sauerstoffes aus dem Pfortaderblut und h~lt somit die metabolischen Anforderungen der Leber aufrecht, wobei die Durchflul3rate und der Sauerstoffpartialdruck der Pfortader nicht wesentlich ver/indert werden [1,23]. B. Operationsschock, Hypoxie, Septik~mie, Gallengangsocclusionen u. a. ist die alleinige Sauerstoffversorgung durch die Pfortader nicht ausreichend [9]. B. Operationsschock, Hypoxie, Septik~mie, Gallengangsocclusionen u. a. ist die alleinige Sauerstoffversorgung durch die Pfortader nicht ausreichend [9].…”

“…traumatische Durchtrennungen der Leberarterie mit teils fatalen, teils komplikationslosen Verlauf beobachten [8,9]. traumatische Durchtrennungen der Leberarterie mit teils fatalen, teils komplikationslosen Verlauf beobachten [8,9].…”

Ligation of both the cœliac axis and superior mesenteric artery with survival of the patient

“…Two cases of hepatic aneurysm were recorded by Grant, Fitts, and Ravdin (1950) with ligation of the hepatic artery but both were fatal. Graham and Cannell (1933) reported a case of accidental ligation of the hepatic artery and reviewed the literature of 27 such cases. They concluded that hepatic artery ligation, although potentially serious, was not necessarily fatal.…”