Keywords
laparoscopic cholecystectomy - middle hepatic vein - hemorrhage
Cholelithiasis is a major public health problem in developed countries, affecting
up to 20% of the population.[1] Cholelithiasis is responsible for 90 to 95% of cases of acute cholecystitis, and
2% of patients with nonsevere cholecystitis experience recurrence within 8 to 10 weeks.[2] Cholecystectomy is the first choice for the treatment of symptomatic cholelithiasis,
especially for patients with acute cholecystitis.[3] Intraoperative complications of laparoscopic cholecystectomy include: bile duct
and organ injury and bleeding due to vascular injury. Uncontrollable hemorrhage during
laparoscopic cholecystectomy occurs in 0.1 to 1.9% of all cases,[4] leading to conversion to open surgery in up to 2% of all laparoscopic cholecystectomies.
Furthermore, in 88% of these events, bleeding originates from the gallbladder bed.[5] The gallbladder bed is reported as a common vascular injury site, mostly secondary
to trauma to the middle hepatic vein.[6] We present a case report of the management of a middle hepatic vein injury during
laparoscopic cholecystectomy.
Case Presentation
A 67-year-old male presented to our hospital after experiencing right upper quadrant
abdominal pain for the last 2 weeks. Clinical history included treatment for follicular
B lymphoma, stage IIA, and during his checkups a computed tomography (CT) scan of
the abdomen was performed describing the presence of cholelithiasis. The patient was
scheduled for an elective laparoscopic gallbladder removal on an outpatient basis.
The day of the surgery, the patient was in good general health with normal vital signs.
Abdominal examination revealed mild abdominal pain without signs of an acute abdomen.
During the procedure, the hepatocystic triangle was dissected without complications.
During dissection of the gallbladder from the cystic plate, a major venous hemorrhage
erupted. Direct compression and electrocautery were not successful in controlling
the bleeding. [Fig. 1]. Due to continuous bleeding, hemodynamic changes and the inability to control bleeding
with laparoscopy, the laparoscopy was aborted and a supraumbilical laparotomy incision
was performed. The bleeding was controlled with ligation of the vessel and the peritonization
of the gallbladder bed. The patient had a successful recovery and was discharged on
postoperative day 3. On outpatient follow-up, the patient remained asymptomatic.
Fig. 1 Dissection of the gallbladder bed during laparoscopy. A vascular structure was observed
producing significant amount of blood (arrow on the upper image).
Discussion
Laparoscopic cholecystectomy has been established as the gold standard for the treatment
of gallstone disease, but it can be associated with significant morbidity and mortality.[7] Bleeding complications are an important cause of mortality, especially when facing
major bleeding during a laparoscopic procedure where the bleeding control can be technically
challenging. Between 10 and 15% of patients will display a large branch of the middle
hepatic vein adherent to the gallbladder bed, presenting an increased risk of vein
injury during cholecystectomy. Excluding major vessels, bleeding can originate from
the gallbladder bed itself, and the middle hepatic vein has been described to be a
cause of uncontrollable bleeding.[4]
[8] Misawa et al reported that the branch of the middle hepatic vein was completely
adherent to the gallbladder bed in 5 of the 50 patients, and in one patient the diameter
of the branch was 3.5 mm. In three patients, branch diameters were 3.0 to 3.8 mm traversed
as close as 1.0 mm from the gallbladder bed.[6] The literature describes varies reflections on how to face this possible complication.
Some proposed strategies include delayed cholecystectomy and using low energy cauterization.
Other suggestions include a screening method to determine the middle hepatic vein
distance from the gallbladder bed before laparoscopy.[6] As reported in this case, middle hepatic vein injury is an uncommon yet eventful
situation. It is critical that the surgeon keeps in mind this anatomy, especially
during the final steps of gallbladder dissection from the plate during laparoscopic
cholecystectomy [Fig. 2].
Fig. 2 Middle hepatic vein seen in laparoscopy.
