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 cholelithiasis /cho·le·li·thi·a·sis/ (ko?le-li-thi´ah-sis) the presence or formation of gallstones. cho·le·li·thi·a·sis n. was admitted to our hospital for elective laparoscopic cholecystectomy Laparoscopic cholecystectomy Removal of the gallbladder using a laparoscope, a fiberoptical instrument inserted through the abdomen. Mentioned in: General Surgery 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 hemostasis /he·mo·sta·sis/ (he?mo-sta´sis) (he-mos´tah-sis) 1. the arrest of bleeding by the physiological properties of vasoconstriction and coagulation or by surgical means. 2. was achieved using sutures, clips and diathermy diathermy (dī`əthûr'mē), therapeutic measure used in medicine to generate heat in the body tissues. Electrodes and other instruments are used to transmit electric current to surface structures, thereby increasing the local blood , and no bile duct bile duct or biliary duct n. Any of the excretory ducts in the liver that convey bile between the liver and the intestine, including the hepatic, cystic, and common bile ducts. Also called gall duct. bile duct 1. or vascular injuries were recognized intraoperatively. Because of severe right upper quadrant right upper quadrant Physical exam The abdominal region that contains the liver, duodenum and head of pancreas abdominal pain and significant deterioration of the liver function tests Liver Function Tests Definition Liver function tests, or LFTs, include tests for bilirubin, a breakdown product of hemoglobin, and ammonia, a protein byproduct that is normally converted into urea by the liver before being excreted by the kidneys. (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 Ischemic An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery. Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation ischemic liver on the right, a transected common bile duct common bile duct n. The duct that is formed by the union of the hepatic and cystic ducts and discharges into the duodenum. Also called gall duct. at the level of its confluence, a divided and ligated right hepatic artery and thrombosed thrombosed /throm·bosed/ (throm´bozd) affected with thrombosis. throm·bosed adj. 1. Clotted. 2. Of, being, or characterizing a blood vessel that is the seat of thrombosis. portal vein down to its confluence. Thrombectomy thrombectomy /throm·bec·to·my/ (throm-bek´tah-me) surgical removal of a clot from a blood vessel. throm·bec·to·my n. Excision of a thrombus. 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 pa·ren·chy·ma n. 1. Anatomy The tissue characteristic of an organ, as distinguished from associated connective or supporting tissues. 2. 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 Words: laparoscopic cholecystectomy, bile duct injury, hepatic artery injury, portal vein injury, hepatectomy hep·a·tec·to·my n. Excision of liver tissue. hepatectomy surgical excision of liver tissue. hepatectomy Surgery Segmental resection of the liver Indications Cancer, parasites, major trauma–eg, MVAs , liver resection ********** Laparoscopic cholecystectomy (LC) constitutes the operation of choice for symptomatic gallstone disease. (1) Meanwhile, a 0.62% incidence of postcholecystectomy biliary injury has been reported. (2) Concomitant vascular injuries complicate the course of these patients with an incidence of 47%. (3) The combination of biliary and vascular injury following LC contributes significantly to the postoperative morbidity and mortality Morbidity and Mortality can refer to:
Case Report A 75-year-old female patient suffering from symptomatic cholelithiasis underwent elective laparoscopic cholecystectomy (LC). Because of severe inflammation and dense adhesions at the region of Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, LC was converted to an open procedure through a standard right subcostal subcostal /sub·cos·tal/ (-kos´t'l) below a rib or ribs. subcostal below a rib or ribs. incision. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct injury was recognized intraoperatively. On the first postoperative day, the patient complained of constant and severe right upper quadrant abdominal pain, while liver function tests (LFTs) were significantly elevated: aspartate aminotransferase (AST (AST Computer, Irvine, CA) A PC manufacturer founded in 1980 by Albert Wong, Safi Quershey and Tom Yuen (A, S and T). It offered a complete line of PCs that sold through its dealer channel. ) 5250 IU/L (normal: 5-40 IU/L), alanine aminotransferase (ALT) 4672 IU/L (normal: 5-40 IU/L), total bilirubin Bilirubin The predominant orange pigment of bile. It is the major metabolic breakdown product of heme, the prosthetic group of hemoglobin in red blood cells, and other chromoproteins such as myoglobin, cytochrome, and catalase. 2.7 mg/dL (normal: 0.2-1.0 mg/dL). Evaluation with Doppler ultrasonography showed no portal flow due to occlusive occlusive /oc·clu·sive/ (o-kloo´siv) pertaining to or causing occlusion. oc·clu·sive adj. 1. Occluding or tending to occlude. 2. thrombus thrombus /throm·bus/ (throm´bus) pl. throm´bi a stationary blood clot along the wall of a blood vessel, frequently causing vascular obstruction. of the portal axis down to the splenomesenteric confluence. Urgent relaparotomy revealed an ischemic liver, especially on the right. The common bile duct was found to be transected and suture ligated at the level of its confluence. The right hepatic artery was also found to be divided between clips. The left and proper hepatic arteries were found to be intact, both by palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. and intraoperative Doppler ultrasound. The right portal vein was suture ligated while its main tract was thrombosed down to the splenomesenteric confluence. The bowel wall did not show any signs of ischemia or congestion The condition of a network when there is not enough bandwidth to support the current traffic load. congestion - When the offered load of a data communication path exceeds the capacity. . Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver. After restoration of the blood flow to the left liver, right hemihepatectomy and an end-to-side Roux-en-Y hepaticojejunostomy on the left were performed (Fig.). Postoperatively, the patient was transferred to the ICU ICU intensive care unit. ICU abbr. intensive care unit ICU see intensive care unit. ICU . Her postoperative recovery was complicated by pneumonia and Acinetobacter baumanni was isolated from sputum cultures. Despite normal liver function tests and Doppler ultrasound findings, as well as proper antibiotic therapy administration, the patient died on the 16th postoperative day due to uncontrolled sepsis. Literature Review A MEDLINE The online medical database of the U.S. National Library of Medicine (NLM) whose parent is the National Institutes of Health, Bethesda, MD. MEDLINE contains millions of articles from thousands of medical journals and publications. The consumer section of the site (http://medlineplus. database search was conducted using the following key words: laparoscopic cholecystectomy, bile duct injury (BDI BDI Burundi (ISO Country code) BDI Beck Depression Inventory BDI Belief-Desire-Intention (AI agents) BDI Baltic Dry Index BDI Basic Driver Improvement (traffic school) ), hepatic artery injury (HAI HAI Health Action International HAI Healthcare-Associated Infections HAI Helicopter Association International HAI Hospital Acquired Infection HAI Hemagglutination Inhibition (Immune assay type, microbiology) ), (2) portal vein injury (PVI See Present Value Index. ), hepatectomy, and liver resection. References were limited to articles of which the abstract at least was in the English language. Liver resections were classified according to the International Hepato-Pancreato-Biliary Association (IHPBA IHPBA International Hepato-Pancreato-Biliary Association ) recommendations. (9) Discussion Isolated BDI rarely requires liver resection for management of its long-term complications. (10) However, the simultaneous presence of vascular injury worsens the clinical course of the patient because of the development of complications such as liver necrosis and biliary stricture stricture /stric·ture/ (strik´chur) stenosis. stric·ture n. A circumscribed narrowing of a hollow structure. . (4,8,11) As right hepatic artery (RHA RHA Residence Hall Association RHA Regional Health Authority RHA Road Haulage Association RHA Rental Housing Association RHA Royal Horse Artillery (a British Regiment) RHA Royal Hibernian Academy ) frequently runs closely and parallel to the cystic duct, it is more vulnerable to injury (12,13) and can be easily ligated if the structures in the Calot triangle are not clearly identified. (14) Although occlusion of the RHA is usually well tolerated because collaterals from the diaphragm and retroperitoneum support the liver, (11,15) the development of intrahepatic abscess abscess, localized inflamation associated with tissue necrosis. Abscesses are characterized by inflamation, which is due to the accumulation of pus in the local tissues, and often painful swelling. , (11) ischemic necrosis of the right hepatic lobe, (11) recurrent episodes of cholangitis and subsequent secondary biliary cirrhosis, (11) as well as liver atrophy, have been reported as long-term complications, which might require liver resection for successful treatment. The incidence of liver necrosis with or without abscess formation has been reported to be as high as 75% (16) in patients with BDI and arterial injury. Almost half of such patients who underwent bilioenteric anastomosis anastomosis /anas·to·mo·sis/ (ah-nas?tah-mo´sis) pl. anastomo´ses [Gr.] 1. communication between vessels by collateral channels. 2. for the BDI treatment developed postoperative biliary leak due to either primary hepaticojejunostomy failure (17) or late peripheral biliary duct stenosis of ischemic origin. (17) Thus, patients with confirmed bile duct injury should be evaluated for concomitant hepatic arterial injury and if this is present, should be treated immediately. (6) The literature addresses that hepatectomy is more common when a BDI is combined with an RHA injury, compared with isolated BDI. (12) Combined biliary duct and hepatic artery injury require various types of hepatic resections to treat mainly secondary biliary cirrhosis (Table 1). (3,6,10-12,18-22) [FIGURE OMITTED] Since an intact portal circulation is mandatory for hepatic parenchyma Parenchyma A ground tissue of plants chiefly concerned with the manufacture and storage of food. The primary functions of plants, such as photosynthesis, assimilation, respiration, storage, secretion, and excretion—those associated with living oxygenation oxygenation /ox·y·gen·a·tion/ (ok?si-je-na´shun) 1. the act or process of adding oxygen. 2. the result of having oxygen added. in cases of hepatic artery injury and is a prerequisite for successful reconstruction in a dearterialized hepatic parenchyma, (6) the portal blood flow should be thoroughly examined in any case of BDI and RHA injury following LC. In fact, 9 cases of combined biliary duct, hepatic artery and portal vein injury following LC requiring liver resections have been previously reported (3,4,8,23) (Table 2). Patients with biliovascular injuries status post LC, involving both the hepatic artery and portal vein branches, as compared with biliovascular injuries involving the hepatic artery branch alone present earlier (median time interval: 17.5 d versus 97.5 d, respectively) and are most likely to have undergone formal hepatectomies rather than partial liver resections. The liver resection may be performed in an acute (minutes to hours after injury), late acute (days after the injury) or late (weeks after injury) setting. (21,24) The majority of the reported combined injuries (BDI + RHA [+ or -] PVI) (Tables 1 and 2) were recognized neither at the time of the LC, nor during the early postoperative period. To our knowledge, the present case is the first reported in the English literature in which liver resection was done in an acute setting (20 hour). The dry operative field, the immediate identification of the injured structures, as well as the absence of severe inflammatory reaction, contributed to the immediate restoration of the blood flow to the liver and the salvage of the left hemiliver. The elapsed e·lapse intr.v. e·lapsed, e·laps·ing, e·laps·es To slip by; pass: Weeks elapsed before we could start renovating. n. period between the time of a bile duct injury and the time of referral has been proposed as a significant predictor of outcome (6) since delay in the diagnosis of a combined vascular injury, as well as long-term conservative management, makes the situation more burdensome for the surgeon. (8,12,25,26) Delayed diagnosis of vascular lesions leads to difficulty with revascularization and reconstruction, resulting in hepatic necrosis and liver cirrhosis. (6) In conclusion, liver resection may serve an important role in cases of parenchymal necrosis, liver atrophy, massive bleeding or intraparenchymal bile duct injuries in cases of complicated biliovascular injury, including PVI, following LC. The present case suggests that major liver resection status post combined BDI and vascular injury can be safely performed in an acute setting. References 1. McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic Laparoscopic A minimally-invasive surgical or diagnostic procedure that uses a flexible endoscope (laparoscope) to view and operate on structures in the abdomen. Mentioned in: Obstetrical Emergencies versus mini-laparotomy cholecystectomy Cholecystectomy Definition A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach. : a randomised Adj. 1. randomised - set up or distributed in a deliberately random way randomized irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" 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 frilling separation of the photographic emulsion from the film base commencing at the edges of the film. Usually caused by prolonged immersion in a liquid at too high a temperature. 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 lobectomy /lo·bec·to·my/ (lo-bek´tah-me) excision of a lobe, as of the lung, brain, or liver. lo·bec·to·my n. Excision of a lobe of an organ or a gland. for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 1999;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 iatrogenic /iat·ro·gen·ic/ (i-a´tro-jen´ik) resulting from the activity of physicians; said of any adverse condition in a patient resulting from treatment by a physician or surgeon. 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 Cholecystitis Definition Cholecystitis refers to a painful inflammation of the gallbladder's wall. The disorder can occur a single time (acute), or can recur multiple times (chronic). 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 ANZ Australia and New Zealand ANZ Australia and New Zealand Banking Group Limited ANZ Air New Zealand (NZ national airline) 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. 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, and Gregorios Kouraklis, MD From the Department of Surgery, University of Athens, Medical School, LAIKO Hospital, Athens, Greece. Reprint requests to Dr. Othon P. Michail, 30 Roumbessi str, Halandri, Athens, Greece. Email: omichail@yahoo.com Accepted July 13, 2006. RELATED ARTICLE: 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.
Table 1. Hepatic resections for combined biliary and hepatic artery
injuries following laparoscopic surgery
No. of
Reference patients Elapsed period Type of injury
Alves (3) 8 361 days mean BDI + HAI
Stewart et al (12) 4 NA Various types of
BDI + RHA
Schmidt et al (11) 2 1st pt: 4 months RHD + RHA
2nd pt: 8 months RHD + RHA
Uenishi et al (18) 1 13 months Hilar BD + RHA
Kayaalp et al (19) 2 1st pt: 2 weeks BD + RHA
2nd pt: 4 days CBD + RHA
Sekido et al (20) 2 1st pt: 2, 5 months CHD + RHA
2nd pt: 5 months CBD + RHA
Soderlund et al (21) 2 1st pt: 4 months CHD + RHA
2nd pt: 8 months HC + RHA
Frilling et al (6) 5 Median interval: Various types of
12 days BDI + RHA
Slater et al (22) 8 1 to 8 months
Perini et al (10) 2 Median interval: RHD + RHA
32 days
Treatment/liver
Reference resection Outcome
Alves (3) RHHx + R-en-Y HJ Well, mean 56 months
Stewart et al (12) 3 pts: Partial RHHx Well, time NA
1 pt: RHHx Well, time NA
Schmidt et al (11) RHHx + LHJ Well, 31 months
RHHx + LHJ Well, 54 months
Uenishi et al (18) RHHx + LHJ Well, 25 months
Kayaalp et al (19) RHHx Died, 22 p.o day
RHHx + LHJ Well, 36 months
Sekido et al (20) RHHx Well, 36 months
RHHx Well, 16 months
Soderlund et al (21) RHHx + LHJ Well, 31 months
RHHx + LHJ Well, 54 months
Frilling et al (6) 5 pts: RHHx Well, median 16 months
Slater et al (22) 5 pts: RHHx Well, median 60 months
1 pt: Resection segment 4
1 pt: LHHx
1 pt: Right Anterior
Sectionectomy
Perini et al (10) 2 pts: RHHx Well, median 44 months
BDI, bile duct injury; CBD, common bile duct; RHD, right hepatic duct;
CHD, common hepatic duct; HC, hepatic confluence; RHA, right hepatic
artery; HAI, hepatic artery injury; RHHx, right hemihepatectomy; LHJ,
left hepaticojejunostomy; p.o., postoperative; R-en-Y HJ = Roux-en-Y
hepaticojejunostomy; LHHx, left hemihepatectomy.
Table 2. Hepatic resections for combined biliary, hepatic artery and
portal vein injuries following LC
No. of
Reference patients Elapsed period Type of injury
Alves et al (3) 4 361 days 3 pts: BDI + RHA + PV
1 pt: BDI + PV
Nishio et al (8) 1 135 days HC + RHA + Right
anterior PVB
Madariaga et al (4) 2 1st pt: 5 days CHD + RHA + PV
2nd pt: 21 days CHD + RHA + Right
posterior PVB
Heinrich et al (23) 1 2 weeks RHD + RHA + RPV
Present case 1 20 hrs CBD + RHA + RPV
Treatment/liver
Reference resection Outcome
Alves et al (3) Right hepatectomy + Well, mean 56 months
R-en-Y HJ
Nishio et al (8) RHHx Well, 25 months
Madariaga et al (4) RHHx + LHJ and PVR Well, 16 months
RHHx, LHJ and CHJ Well, 14 months
Heinrich et al (23) RHHx Well, 11 months
Present case RHHx + LHJ Died, 16th day in ICU
CBD, common bile duct; HC, hepatic confluence; RHD, right hepatic duct;
RHA, right hepatic artery; PVB, portal vein branch; PV, portal vein;
RHHx, right hemihepatectomy; LHJ, left hepaticojejunostomy; CHJ, caudate
hepaticojejunostomy; R-en-Y HJ = Roux-en-Y hepaticojejunostomy; RPV,
right portal vein.
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