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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic repair for intraoperative injury of the right hepatic artery during cholecystectomy Shuichi Fujioka,1 Azusa Fuke,1 Naotake Funamizu,1 Tomoko Nakayoshi,1 Tomoyoshi Okamoto1 & Katsuhiko Yanaga2 1 Department of Surgery, Jikei Daisan Hospital, Tokyo, Japan 2 Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
Keywords Laparoscopic cholecystectomy; right hepatic artery; vascular injury Correspondence Shuichi Fujioka, 4-11-1, Izumi-honcho, Komae City, Tokyo 201-0003, Japan. Tel: +81 3 3480 1151 Fax: +81 3 3480 5467 Email: [email protected] Received 30 June 2014; revised 24 July 2014; accepted 8 August 2014 DOI:10.1111/ases.12151
Abstract Right hepatic artery (RHA) injury is a complication that occurs during laparoscopic cholecystectomy, which can sometimes cause hepatic artery pseudoaneurysm or ischemic hepatic necrosis. Therefore, RHA should be managed carefully. Herein, we report a case of intraoperative RHA injury that was successfully repaired during laparoscopic cholecystectomy. Bleeding was controlled prior to the cholecystectomy with vascular clamp forceps that had been inserted through an additional trocar, and repair of the RHA injury was then performed laparoscopically. The postoperative course was uneventful, and patency of the RHA and its sectional arteries were confirmed by CT arteriography. Laparoscopic repair of minor RHA injuries can be managed safely if bleeding is adequately controlled.
Introduction Right hepatic artery (RHA) injury is a common variant of vasculobiliary injury that occurs during laparoscopic cholecystectomy (LC); it is frequently encountered concomitantly with bile duct injury. Although the actual number of repairs reported is very small, the true incidence of RHA injury without concomitant bile duct injury is not clear. This is presumably because laparoscopic repair is deemed difficult: hemostasis must be achieved shortly after the injury, so laparoscopic repair is reserved for minor injuries. Here, we report, to our knowledge, the first successful laparoscopic repair of RHA injury during LC.
Case Presentation An 82-year-old woman was admitted with a clinical diagnosis of cholelithiasis. Elective LC using the standard four-trocar technique was scheduled. At operation, the gallbladder was mildly inflamed and contained multiple stones. RHA was identified just behind the cystic duct, within the right portal pedicle. During dissection
of the gallbladder bed, the peripheral part of the RHA running behind the cystic plate was injured by a hooktype electrosurgical knife. An additional 5-mm trocar was inserted ventral to the bleeding point, and the arterial bleeding was controlled by placing a vascular clamp proximally. Under good hemostasis, the cystic artery and cystic duct were clipped and divided. The remaining gall bladder dissection around the cystic plate was completed, and the gallbladder was excised. Next, laparoscopic suturing of the arterial injury was attempted with a 4-0 monofilament Prolene (Ethicon-Endo Surgery, Cincinnati, USA) suture. The first bite was placed on the deepest edge of the injured point of the RHA as the anchor thread; this facilitated the second bite and did not grasp the arterial wall in the limited space under laparoscopy. The injured site of the RHA was visualized and then closed with a 4-0 Prolene running suture (Figure 1). The postoperative course was uneventful and without abnormality in the liver chemistry. CT angiography on postoperative day 5 demonstrated patency of the RHA and its sectional arteries, without any stenosis, occlusion, or pseudoaneurysm formation (Figure 2, white arrow).
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
75
Laparoscopic right hepatic artery repair
S Fujioka et al.
Figure 1 Intraoperative pictures. The injured RHA was immediately repaired by suturing. RHA, right hepatic artery.
Discussion Concomitant injury of the RHA and bile duct is a common complication during LC, accounting for approximately 90% of vasculobiliary injuries (1). However, estimating the actual incidence of isolated RHA injury during cholecystectomy is difficult because RHA injuries rarely produce clinical symptoms. In a study of cadavers that had undergone cholecystectomy prior to death, Halasz reported that the incidence of injury to the RHA or its branches was 7% (5/71), but there was no liver or bile duct abnormality (2). This asymptomatic RHA injury is probably due to the collateral blood supply after occlusion of the RHA, which occurs from the left or middle hepatic artery through the hilar communicating artery and functions as a pre-formed collateral arterial route (3–5). This communicating arterial flow is recognized as early as 10 h after RHA injury, and total hepatic
76
arterial flow approaches normal levels within 4 days after injury (5). Although preformed shunts may open immediately, the interval for these shunts to attain maximum flow remains unknown. Thus, the decision not to repair the RHA may result in slow infarction of the liver. Slow hepatic infarction is likely to occur in less than 10%, of cases because the incidence of right liver infarction in patients with concomitant injury of the RHA and bile duct is estimated to be approximately 10% (1). Although immediate repair of the RHA remains conventional, it is rarely possible, and the benefit of such a principle has not been clearly demonstrated. Therefore, pooling of data and standardized reporting of injuries should help to further delineate the consequences of arterial injuries in LC. In our case, we attempted to immediately repair the RHA injury laparoscopically. As reported by Strasberg
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Laparoscopic right hepatic artery repair
S Fujioka et al.
Figure 2 Postoperative imaging. CT arteriogram shows the patency of the right hepatic artery and its sectional arteries.
and Gouma and in the present case, RHA injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation (6). Cholecystectomy is often unfinished at the time of the RHA injury, but completing the cholecystectomy gives a better surgical view for repair of the RHA, which can be performed only once the bleeding has been controlled. In our case, we immediately attempted to control the arterial bleeding with vascular clamping forceps inserted through an additional trocar and applied ventral to the bleeding point before cholecystectomy. Laparoscopic repair of the RHA ought to be decided according to the extent of the injury. For example, it should be applied when less than one-third of the RHA’s entire circumference has been injured. In the present case, we decided to repair the RHA because the injury was estimated to affect between one-fourth and onethird of the RHA circumference. Placing the anchoring suture distal to the injured point was especially useful for evaluating the details of the injury and securing repair by effective suture placement. We repaired the injury by transverse placement of the suture to prevent occlusion of the RHA or its sectional arteries. During the repair of the RHA, it was important for the assistant to ensure the operative field by washing out and suctioning the blood clot around the injured point and by controlling the clamping forceps on the RHA as the anchoring suture
was placed. The magnified laparoscopic view helped with precise needle placement in the injured area of the RHA. In conclusion, for simple and minor injuries of the RHA, laparoscopic repair of the RHA is feasible.
Acknowledgment The authors have no conflicts of interest to report and received no funding for this report.
References 1. Strasberg SM & Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB 2011; 13: 1–14. 2. Halasz NA. Cholecystectomy and hepatic artery injuries. Arch Surg 1991; 126: 137–138. 3. Redman HC & Reuter SR. Arterial collaterals in the liver hilus. Radiology 1970; 94: 575–579. 4. Bengmark S & Rosengren K. Angiographic study of the collateral circulation to the liver after ligation of the hepatic artery in man. Am J Surg 1970; 119: 620–624. 5. Mays ET & Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med 1974; 290: 993–996. 6. Strasberg SM & Gouma DJ. “Extreme” vasculobiliary injuries: Association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB 2012; 14: 1–8.
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
77
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic repair for intraoperative injury of the right hepatic artery during cholecystectomy Shuichi Fujioka,1 Azusa Fuke,1 Naotake Funamizu,1 Tomoko Nakayoshi,1 Tomoyoshi Okamoto1 & Katsuhiko Yanaga2 1 Department of Surgery, Jikei Daisan Hospital, Tokyo, Japan 2 Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
Keywords Laparoscopic cholecystectomy; right hepatic artery; vascular injury Correspondence Shuichi Fujioka, 4-11-1, Izumi-honcho, Komae City, Tokyo 201-0003, Japan. Tel: +81 3 3480 1151 Fax: +81 3 3480 5467 Email: [email protected] Received 30 June 2014; revised 24 July 2014; accepted 8 August 2014 DOI:10.1111/ases.12151
Abstract Right hepatic artery (RHA) injury is a complication that occurs during laparoscopic cholecystectomy, which can sometimes cause hepatic artery pseudoaneurysm or ischemic hepatic necrosis. Therefore, RHA should be managed carefully. Herein, we report a case of intraoperative RHA injury that was successfully repaired during laparoscopic cholecystectomy. Bleeding was controlled prior to the cholecystectomy with vascular clamp forceps that had been inserted through an additional trocar, and repair of the RHA injury was then performed laparoscopically. The postoperative course was uneventful, and patency of the RHA and its sectional arteries were confirmed by CT arteriography. Laparoscopic repair of minor RHA injuries can be managed safely if bleeding is adequately controlled.
Introduction Right hepatic artery (RHA) injury is a common variant of vasculobiliary injury that occurs during laparoscopic cholecystectomy (LC); it is frequently encountered concomitantly with bile duct injury. Although the actual number of repairs reported is very small, the true incidence of RHA injury without concomitant bile duct injury is not clear. This is presumably because laparoscopic repair is deemed difficult: hemostasis must be achieved shortly after the injury, so laparoscopic repair is reserved for minor injuries. Here, we report, to our knowledge, the first successful laparoscopic repair of RHA injury during LC.
Case Presentation An 82-year-old woman was admitted with a clinical diagnosis of cholelithiasis. Elective LC using the standard four-trocar technique was scheduled. At operation, the gallbladder was mildly inflamed and contained multiple stones. RHA was identified just behind the cystic duct, within the right portal pedicle. During dissection
of the gallbladder bed, the peripheral part of the RHA running behind the cystic plate was injured by a hooktype electrosurgical knife. An additional 5-mm trocar was inserted ventral to the bleeding point, and the arterial bleeding was controlled by placing a vascular clamp proximally. Under good hemostasis, the cystic artery and cystic duct were clipped and divided. The remaining gall bladder dissection around the cystic plate was completed, and the gallbladder was excised. Next, laparoscopic suturing of the arterial injury was attempted with a 4-0 monofilament Prolene (Ethicon-Endo Surgery, Cincinnati, USA) suture. The first bite was placed on the deepest edge of the injured point of the RHA as the anchor thread; this facilitated the second bite and did not grasp the arterial wall in the limited space under laparoscopy. The injured site of the RHA was visualized and then closed with a 4-0 Prolene running suture (Figure 1). The postoperative course was uneventful and without abnormality in the liver chemistry. CT angiography on postoperative day 5 demonstrated patency of the RHA and its sectional arteries, without any stenosis, occlusion, or pseudoaneurysm formation (Figure 2, white arrow).
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
75
Laparoscopic right hepatic artery repair
S Fujioka et al.
Figure 1 Intraoperative pictures. The injured RHA was immediately repaired by suturing. RHA, right hepatic artery.
Discussion Concomitant injury of the RHA and bile duct is a common complication during LC, accounting for approximately 90% of vasculobiliary injuries (1). However, estimating the actual incidence of isolated RHA injury during cholecystectomy is difficult because RHA injuries rarely produce clinical symptoms. In a study of cadavers that had undergone cholecystectomy prior to death, Halasz reported that the incidence of injury to the RHA or its branches was 7% (5/71), but there was no liver or bile duct abnormality (2). This asymptomatic RHA injury is probably due to the collateral blood supply after occlusion of the RHA, which occurs from the left or middle hepatic artery through the hilar communicating artery and functions as a pre-formed collateral arterial route (3–5). This communicating arterial flow is recognized as early as 10 h after RHA injury, and total hepatic
76
arterial flow approaches normal levels within 4 days after injury (5). Although preformed shunts may open immediately, the interval for these shunts to attain maximum flow remains unknown. Thus, the decision not to repair the RHA may result in slow infarction of the liver. Slow hepatic infarction is likely to occur in less than 10%, of cases because the incidence of right liver infarction in patients with concomitant injury of the RHA and bile duct is estimated to be approximately 10% (1). Although immediate repair of the RHA remains conventional, it is rarely possible, and the benefit of such a principle has not been clearly demonstrated. Therefore, pooling of data and standardized reporting of injuries should help to further delineate the consequences of arterial injuries in LC. In our case, we attempted to immediately repair the RHA injury laparoscopically. As reported by Strasberg
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Laparoscopic right hepatic artery repair
S Fujioka et al.
Figure 2 Postoperative imaging. CT arteriogram shows the patency of the right hepatic artery and its sectional arteries.
and Gouma and in the present case, RHA injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation (6). Cholecystectomy is often unfinished at the time of the RHA injury, but completing the cholecystectomy gives a better surgical view for repair of the RHA, which can be performed only once the bleeding has been controlled. In our case, we immediately attempted to control the arterial bleeding with vascular clamping forceps inserted through an additional trocar and applied ventral to the bleeding point before cholecystectomy. Laparoscopic repair of the RHA ought to be decided according to the extent of the injury. For example, it should be applied when less than one-third of the RHA’s entire circumference has been injured. In the present case, we decided to repair the RHA because the injury was estimated to affect between one-fourth and onethird of the RHA circumference. Placing the anchoring suture distal to the injured point was especially useful for evaluating the details of the injury and securing repair by effective suture placement. We repaired the injury by transverse placement of the suture to prevent occlusion of the RHA or its sectional arteries. During the repair of the RHA, it was important for the assistant to ensure the operative field by washing out and suctioning the blood clot around the injured point and by controlling the clamping forceps on the RHA as the anchoring suture
was placed. The magnified laparoscopic view helped with precise needle placement in the injured area of the RHA. In conclusion, for simple and minor injuries of the RHA, laparoscopic repair of the RHA is feasible.
Acknowledgment The authors have no conflicts of interest to report and received no funding for this report.
References 1. Strasberg SM & Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB 2011; 13: 1–14. 2. Halasz NA. Cholecystectomy and hepatic artery injuries. Arch Surg 1991; 126: 137–138. 3. Redman HC & Reuter SR. Arterial collaterals in the liver hilus. Radiology 1970; 94: 575–579. 4. Bengmark S & Rosengren K. Angiographic study of the collateral circulation to the liver after ligation of the hepatic artery in man. Am J Surg 1970; 119: 620–624. 5. Mays ET & Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med 1974; 290: 993–996. 6. Strasberg SM & Gouma DJ. “Extreme” vasculobiliary injuries: Association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB 2012; 14: 1–8.
Asian J Endosc Surg 8 (2015) 75–77 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
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