Laparoscopic Cholecystectomy After Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery: Report of a Case

Abstract

A laparoscopic cholecystectomy (LC) was successfully performed on a 61-year-old man who had undergone coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). He complained of right hypochondralgia 20 days after CABG. Gallstones were diagnosed and a cholecystectomy was performed 9 months after CABG. Under general anesthesia, the operation was performed using a pneumoperitonium. When a laparoscope was inserted, the RGEA pedicle could be clearly recognized. The pedicle obstructed the operating field and made the working space narrower than usual. No ST changes on the electrocardiogram were seen during LC, especially during the initiation of pneumoperitonium, the insertion of the ports, or when retracting the gallbladder. The postoperative course was uneventful. To avoid complications, care should be taken not to stretch the RGEA pedicle during LC, and careful monitoring of the electrocardiogram is also necessary. It is difficult to view the operating field and the RGEA pedicle together. It is therefore better to insert another laparoscope for concomitant monitoring of the RGEA pedicle.

Laparoscopic right hemicolectomy after coronary artery bypass grafting using the right gastroepiploic artery: A case report

“…Preoperative CT scan was required for understanding the locations of vessels in the right side colon, including the middle colic artery, gastrocolic trunk and accessory right colic vein, since there is considerable variation of these vessels among individuals. After CABG, the anatomical orientation is also particularly important for the RGEA [1]. Adhesion is likely due to previous operative procedures and it is important to remove adhesions carefully and confirm the entire RGEA with attention to the antegastric or retrogastric route.…”

“…Therefore, conservation/ resection of the greater omentum should be considered on a case-by-case basis. Myocardial ischemia may also occur due to traction and excessive stress during surgery, in addition to RGEA injury [1]. Thus, the RGEA should be frequently monitored and confirmed because the limited surgical area can only be observed by laparoscope.…”

“…Several key aspects of the procedure differed from usual LAC. These included the need to minimize postural changes, including the head-up and head-down positions, and to start pneumoperitoneum at lower pressure than usual and gradually increase the pressure to prevent excessive stress on the RGEA [1]. Preoperative CT scan was required for understanding the locations of vessels in the right side colon, including the middle colic artery, gastrocolic trunk and accessory right colic vein, since there is considerable variation of these vessels among individuals.…”

“…Therefore, open surgery is usually performed. However, laparoscopic surgery has recently been applied as upper abdominal surgery for gallstones and gastric cancer after CABG and laparoscopy-assisted colectomy (LAC) is widely used in patients with colon cancer and has been shown to be safe in elderly patients [1,2,6].…”

“…However, several recent case reports have described laparoscopic surgery for gallstones and gastric cancer after CABG with the RGEA [1,2]. Herein, we describe laparoscopic right hemicolectomy conducted safely in a patient with ascending colon cancer after CABG using the RGEA.…”