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

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.

‘Extreme’ vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders

“…Extreme vasculobiliary injuries comprise a small percentage of all vasculobiliary injuries. A recent analysis of the literature 1 identified 25 patients with such injuries, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] accounting for about 10% of all vasculobiliary injuries reported in the literature. 1 This figure corresponds closely to the incidence of 8% estimated in this paper.…”

“…The uncommon type of vasculobiliary injury involves a bile duct(s) and the proper hepatic artery, the common hepatic artery, the main portal vein, the right portal vein, or one of these veins as well as a hepatic artery, possibly including the right hepatic artery 1 . A recent review 1 identified 25 such patients in the literature 4–18 . The consequences of such injuries are much more extreme.…”

“…1 A recent review 1 identified 25 such patients in the literature. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The consequences of such injuries are much more extreme. Hepatic infarction is common, often with rapid onset and frequently necessitating emergency right hepatectomy or urgent DOI:10.1111/j.1477-2574.2011.00393.x liver transplantation.…”

An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy

“…Right hepatic artery VBI is by far the most common VBI. In combination, the papers reviewed for this article describe about 225 patients, 92% of whom had a VBI involving the RHA 3,5,6,25–50 . The remainder involved other arteries, the portal vein alone or the portal vein in combination with arteries, and sometimes included the RHA.…”

Benign biliary strictures

“…Transplantation for iatrogenic biliary injury can be performed acutely but is usually done because of a devastating combined vascular and biliary injury (Felekouras et al, 2007;Zaydfudim et al, 2009). Only rarely does secondary biliary fibrosis resulting from longstanding biliary obstruction progress to true cirrhosis (see Chapter 97A).…”