CASE REPORT
Compressive Hematoma Due to Pseudoaneurysm of the Right Hepatic Artery: A Rare Cause of Obstructive Jaundice After Single-Port Cholecystectomy Solafah Abdalla, MD,* Alphonse Thome, MD,w Vincent Reslinger, MD,* Calina Atanasiu, MD,z Olivier Pellerin, MD,y Marc Sapoval, MD, PhD,y and Ste´phane Bonnet, MD*
Abstract: Single-port laparoscopic cholecystectomy is considered as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy. It is a technically demanding procedure, and no adequately powered trial has assessed the safety of this technique. Vascular injuries are less common than bile duct injuries during this procedure, but they can be rapidly fatal. The development of a right hepatic artery pseudoaneurysm is a rare but serious complication associated with single-port laparoscopic cholecystectomy. Two weeks following a single-port laparoscopic cholecystectomy for angiocholitis, a 40-year-old male patient presented with obstructive jaundice and persistent abdominal pain. The diagnosis of compressive hematoma due to a ruptured right hepatic artery pseudoaneurysm was confirmed by computed tomography scan and angiography. It was successfully treated by selective embolization of the right hepatic artery. In our experience, endovascular management was a noninvasive and effective treatment of ruptured pseudoaneurysms. Key Words: cholecystectomy, single-port cholecystectomy, vascular complication, hepatic artery pseudoaneurysm, embolization
(Surg Laparosc Endosc Percutan Tech 2015;25:e42–e44)
C
onventional laparoscopic cholecystectomy is considered the standard procedure for treating benign gallbladder lithiasis disease1 because it leads to earlier patient mobilization and hospital discharge. However, this technique still has risks of vascular and biliary injuries.2 The single-incision laparoscopic cholecystectomy was first described in 1995 by Paganini et al3 as a form of natural orifice surgery. A literature review showed better cosmetic outcomes, but no trial was adequately powered to assess the safety of this technique: Trastulli et al4 found no differences between single-port and conventional laparoscopic cholecystectomy in terms of adverse events, such as bile leakage, choledocolithiasis, or gallbladder perforation (7.3% vs. 6.6%). Pseudoaneurysm of the right hepatic artery is a rare but potentially fatal vascular complication after cholecystectomy5 and constitutes a diagnostic and therapeutic challenge. The clinical presentation can be either early or Received for publication June 29, 2013; accepted September 30, 2013. From the Departments of *Visceral and Vascular Surgery; wRadiology; zHepatology and Gastro-enterology, Begin University Military Hospital, Saint-Mande´; and yDepartment of Vascular and Oncologic Interventional Radiology, Georges Pompidou European Hospital, Paris, France. The authors declare no conflicts of interest. Reprints: Ste´phane Bonnet, MD, Service de Chirurgie Visce´rale et Vasculaire, Hoˆpital d’Instruction des Arme´es Be´gin, 69, avenue de Paris, Saint-Mande´ Cedex 94163, France (e-mail: bonnet. [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
e42 | www.surgical-laparoscopy.com
delayed after the procedure.6,7 The diagnosis can be suspected in a patient presenting with persistent abdominal pain, upper gastrointestinal bleeding, or obstructive jaundice after cholecystectomy. Embolization of the pseudoaneurysm or the hepatic artery is the treatment of choice in cases of active bleeding, and this approach has high success rates.8 A surgical approach is usually reserved for cases in which embolization failed or the bile duct is compressed. Herein, we report the first case of a compressive hematoma due to a ruptured hepatic artery pseudoaneurysm revealed by jaundice after a single-port cholecystectomy. Hemostasis was obtained after embolization of the right hepatic artery.
CASE REPORT A 40-year-old man was admitted in the emergency department for typical acute biliary cholangitis revealed by the triad of jaundice, fever, and right upper quadrant pain. Morphologic examinations showed an obstruction of the common bile duct due to stones. Endoscopic decompression (including endoscopic retrograde cholangiopancreatography followed by sphincterotomy) associated with the administration of parenteral antibiotics resulted in a favorable clinical course. Elective single-port cholecystectomy was performed 1 month later. The intraoperative exploration revealed macroscopic features of chronic cholecystitis. The dissection was difficult because of
FIGURE 1. Arterial-phase abdominal computed tomography showing dilated left and right hepatic ducts (red arrows) compressed by the hematoma containing aerial levels (red star). The ruptured pseudoaneurysm of the right hepatic artery is situated next to the clip (black arrow).
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015 Compressive Hematoma After Single-Port Cholecystectomy
edema and inflammation, but there was no need to convert or to add a port. The cystic artery originated directly from the right hepatic artery. No cholangiography was performed intraoperatively because of a narrow cystic duct lumen. The final pathologic examination showed xanthogranulomatous cholecystitis. The patient was readmitted on postoperative day 15 at the emergency department for persistent epigastric pain, vomiting, and jaundice. At the time of admission, the patient was not febrile and had no sign of hemodynamic instability. The physical examination showed epigastric and hypochondrium tenderness, hepatomegaly, and intense mucocutaneous icterus. The patient did not complain of hematemesis or melena. The blood test results showed an inflammatory syndrome (leukocytes: 12,730/mm3, C-reactive protein: 86.8 mg/L), anemia (hemoglobin: 10.8 g/dL), and moderate cholestasis with increased bilirubin (total bilirubin: 36 mmol/L, conjugated bilirubin: 16 mmol/L). In addition, the patient had elevated alkaline phosphatase (423 IU/L) and g-glutamyl transferase (515 IU/L) and cytolysis (alanine aminotransferase: 126 IU/L, aspartate aminotransferase: 100 IU/L). The prothrombin level, V-factor, and lipasemia were normal. An abdominal and pelvic computed tomography (CT) was performed in the emergency department, and it revealed an isolated large hematoma (72 60 40 mm) with aerial levels located in the gallbladder fossa and minor active bleeding from the right hepatic artery (Fig. 1). The common bile duct was compressed by the hematoma, and a dilatation of intrahepatic bile ducts was observed (Fig. 1). As a result, a compressive right hepatic artery pseudoaneurysm was suspected. The patient was immediately treated with parenteral antibiotic therapy consisting of piperacilin, tazobactam, and gentamicin. Selective celiac arteriography using a 5 Fr C2 Cobra catheter (Cook, Letchworth, Herts, UK) revealed a ruptured 7 mm diameter pseudoaneurysm arising from the right hepatic artery (Fig. 2) near the surgical clips. The right hepatic artery also presented an eroded aspect. The right hepatic artery was microcatheterized with a Progreat 2.7 Fr microcatheter (Progreat Microcatheter System, Terumo, Japan), and embolization was performed with helical hydrogel microcoils (AZUR Detachable Peripheral HydroCoils, Terumo, Japan). Control arteriography showed a complete exclusion of the pseudoaneurysm and the right hepatic artery (Fig. 3). The downstream bed was well vascularized by an accessory left
FIGURE 3. Selective common hepatic artery arteriography. Helical hydrogel microcoils (black star) are placed in the right hepatic artery. The left hepatic artery (black arrow) arises from the left gastric artery. hepatic artery arising from the left gastric artery. The patient’s postembolization recovery was uneventful with resolution of the jaundice and normalization of inflammatory signs, cytolysis, and bilirubin within 2 days and cholestasis within 1 month. A CT scan was performed 3 days after embolization, and it showed a regressing hematoma (50 47 25 mm), no active bleeding, and no hepatic ischemia. The patient was discharged 4 days after the procedure with a 15-day oral antibiotic treatment including ciprofloxacin and metronidazole. The CT scan performed 3 months after the embolization showed a complete resorption of the hematoma and no dilatation of the intrahepatic and extrahepatic bile ducts. There was also no liver necrosis and no recurrence of the pseudoaneurysm.
DISCUSSION
FIGURE 2. Selective celiac arteriography showing a ruptured pseudoaneurysm (red arrow) of the right hepatic artery. ALHA indicates accessory left hepatic artery; CHA, common hepatic artery, GA, gastroduodenal artery; LGA: left gastric artery; LHA, left hepatic artery; RHA, right hepatic artery.
Copyright
r
During laparoscopic procedures for gallbladder benign lithiasis pathologies, vascular injuries are less common than bile duct injuries, but they can be rapidly fatal.9 Multicenter studies have reported a rate of 0.25% for vascular injuries9 and a rate of 0.6% for hepatic artery pseudoaneurysms8 after conventional laparoscopic cholecystectomy. The symptoms usually appear in the early postoperative period but may be more delayed (7th to 120th postoperative day).6 The single-incision laparoscopic cholecystectomy emerged as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy.4 However, no trial was adequately powered to assess the safety of this technique,4 particularly with respect to vascular injuries. Moreover, this case of pseudoaneurysm of the right hepatic artery after single-port cholecystectomy is the first reported in the literature. The causes of hepatic artery pseudoaneurysms after cholecystectomy may include direct vascular direct trauma, vascular erosion caused by bile contact, and local inflammatory reactions in cases of pancreatitis, cholecystitis, or angiocholitis.10,11 The exact mechanisms of this process are not well understood. This case demonstrated that it is difficult to identify the cause of pseudoaneurysm occurrence retrospectively. However, contributing factors that can explain vascular trauma are usually identified, including a direct lesion of the vascular wall, thermal diffusion through
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e43
Surg Laparosc Endosc Percutan Tech
Abdalla et al
metallic clips placed close to the vascular pedicle,12 vascular erosion due to clip encroachment, or slipping of the surgical clip applied to the cystic artery.13 In addition, anatomic variations and technical difficulties may also explain vascular and bile duct injuries during laparoscopic cholecystectomy. During single-port laparoscopic cholecystectomy, the absence of triangulation makes the use of instruments for suction/irrigation and diathermy more difficult, which can result in less accurate hemostasis than with traditional laparoscopic techniques. The ergonomic limitation due to the versatility of the instruments may lead to an imprecise dissection, especially during detachment of the gallbladder from its hepatic bed.4 In our case, the patient presented with right upper quadrant pain and isolated obstructive jaundice. The first diagnostic hypothesis was a bile duct injury because no intraoperative cholangiography was performed during cholecystectomy. The CT scan was useful in determining the diagnosis of compressive hematoma on the common bile duct due to a ruptured right hepatic artery pseudoaneurysm. Given the recent history of angiocholitis, biological inflammatory signs and images of aerial levels on the gallbladder bed, we suspected an infected hematoma. As a result, we initiated broad-spectrum antibiotic therapy. We chose not to drain the hematoma because the coil embolization was immediately effective. A magnetic resonance cholangiography was not performed because the CT scan led to an accurate diagnosis. However, this examination could have been discussed as a bile duct injury was suspected.14 Arterioembolization has become the first choice of treatment for isolated vascular injuries after laparoscopic cholecystectomy.8 When the intra-arterial approach is not feasible because of abnormal portal flow or surgical hepatic artery ligature, direct transhepatic embolization of the right hepatic artery can be performed with high success rates.7 A surgical approach is indicated when embolization fails or when the proper expertise is not available.7 In our case, selective embolization of the pseudoaneurysm instead of the right hepatic artery could have been discussed. Although the latter option is safe and rarely followed by liver necrosis, there is a risk of pseudoaneurysm recanalization. This outcome is explained by the numerous collaterals that permeabilize after major artery occlusion. Conversely, perprocedure aneurysm rupture is more likely to occur when selective pseudoaneurysm embolization is performed.
CONCLUSIONS A compressive pseudoaneurysm of the right hepatic artery is a rare vascular complication that should be considered in cases of postoperative obstructive jaundice after laparoscopic cholecystectomy. Single-port laparoscopic
e44 | www.surgical-laparoscopy.com
Volume 25, Number 1, February 2015
cholecystectomy is technically demanding, which makes it a potential cause of vascular lesions. In our experience, endovascular management by coil embolization is a noninvasive and effective treatment for ruptured pseudoaneurysms.
REFERENCES 1. Gallstones and laparoscopic cholecystectomy. NIH Consens. Statement 1992;10:1–28. 2. Sarno G, Al-Sarira AA, Ghaneh P, et al. Cholecystectomyrelated bile duct and vasculobiliary injuries. Br J Surg. 2012;99:1129–1136. 3. Paganini A, Lomonto D, Navordino M. One port laparoscopic cholecystectomy in selected patients. Third International Congress on New Technology in Surgery. Luxemburg, 1995. 4. Trastulli S, Cirocchi R, Desiderio J, et al. Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy. Br J Surg. 2013;100:191–208. 5. Chen C-C, Chen B-B, Wang H-P. Upper gastrointestinal bleeding owing to right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. Gastroenterology. 2009;137:5–6. 6. Balsara KP, Dubash C, Shah CR. Pseudoaneurysm of the hepatic artery along with common bile duct injury following laparoscopic cholecystectomy. A report of two cases. Surg Endosc. 1998;12:276–277. 7. Chigot V, Lallier M, Alvarez F, et al. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Pediatr Radiol. 2003;33:24–26. 8. Nicholson T, Travis S, Ettles D, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol. 1999; 22:20–24. 9. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165:9–14. 10. Ahmed I, Tanveer UH, Sajjad Z, et al. Cystic artery pseudoaneurysm: a complication of xanthogranulomatous cholecystitis. Br J Radiol. 2010;83:165–167. 11. Parthenis DG, Skevis K, Stathopoulos V, et al. Postlaparoscopic iatrogenic pseudoaneurysms of the arteries of the peritoneal and retroperitoneal space: case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2009;19:90–97. 12. Hewes JC, Baroni ML, Krissat J, et al. An unusual presentation of hepatic aneurysm as a complication of laparoscopic cholecystectomy. Eur J Surg Acta Chir. 2002; 168:566–568. 13. Halbe S, Ahmed NI, Sundar K, et al. Pseudoaneurysm in gall bladder fossa following laparoscopic cholecystectomy. Indian J Gastroenterol. 1999;18:122. 14. Mazziotti S, Blandino A, Gaeta M, et al. Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings. Abdom Imaging. 2003;28:835–837.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
Compressive Hematoma Due to Pseudoaneurysm of the Right Hepatic Artery: A Rare Cause of Obstructive Jaundice After Single-Port Cholecystectomy Solafah Abdalla, MD,* Alphonse Thome, MD,w Vincent Reslinger, MD,* Calina Atanasiu, MD,z Olivier Pellerin, MD,y Marc Sapoval, MD, PhD,y and Ste´phane Bonnet, MD*
Abstract: Single-port laparoscopic cholecystectomy is considered as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy. It is a technically demanding procedure, and no adequately powered trial has assessed the safety of this technique. Vascular injuries are less common than bile duct injuries during this procedure, but they can be rapidly fatal. The development of a right hepatic artery pseudoaneurysm is a rare but serious complication associated with single-port laparoscopic cholecystectomy. Two weeks following a single-port laparoscopic cholecystectomy for angiocholitis, a 40-year-old male patient presented with obstructive jaundice and persistent abdominal pain. The diagnosis of compressive hematoma due to a ruptured right hepatic artery pseudoaneurysm was confirmed by computed tomography scan and angiography. It was successfully treated by selective embolization of the right hepatic artery. In our experience, endovascular management was a noninvasive and effective treatment of ruptured pseudoaneurysms. Key Words: cholecystectomy, single-port cholecystectomy, vascular complication, hepatic artery pseudoaneurysm, embolization
(Surg Laparosc Endosc Percutan Tech 2015;25:e42–e44)
C
onventional laparoscopic cholecystectomy is considered the standard procedure for treating benign gallbladder lithiasis disease1 because it leads to earlier patient mobilization and hospital discharge. However, this technique still has risks of vascular and biliary injuries.2 The single-incision laparoscopic cholecystectomy was first described in 1995 by Paganini et al3 as a form of natural orifice surgery. A literature review showed better cosmetic outcomes, but no trial was adequately powered to assess the safety of this technique: Trastulli et al4 found no differences between single-port and conventional laparoscopic cholecystectomy in terms of adverse events, such as bile leakage, choledocolithiasis, or gallbladder perforation (7.3% vs. 6.6%). Pseudoaneurysm of the right hepatic artery is a rare but potentially fatal vascular complication after cholecystectomy5 and constitutes a diagnostic and therapeutic challenge. The clinical presentation can be either early or Received for publication June 29, 2013; accepted September 30, 2013. From the Departments of *Visceral and Vascular Surgery; wRadiology; zHepatology and Gastro-enterology, Begin University Military Hospital, Saint-Mande´; and yDepartment of Vascular and Oncologic Interventional Radiology, Georges Pompidou European Hospital, Paris, France. The authors declare no conflicts of interest. Reprints: Ste´phane Bonnet, MD, Service de Chirurgie Visce´rale et Vasculaire, Hoˆpital d’Instruction des Arme´es Be´gin, 69, avenue de Paris, Saint-Mande´ Cedex 94163, France (e-mail: bonnet. [email protected]). Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
e42 | www.surgical-laparoscopy.com
delayed after the procedure.6,7 The diagnosis can be suspected in a patient presenting with persistent abdominal pain, upper gastrointestinal bleeding, or obstructive jaundice after cholecystectomy. Embolization of the pseudoaneurysm or the hepatic artery is the treatment of choice in cases of active bleeding, and this approach has high success rates.8 A surgical approach is usually reserved for cases in which embolization failed or the bile duct is compressed. Herein, we report the first case of a compressive hematoma due to a ruptured hepatic artery pseudoaneurysm revealed by jaundice after a single-port cholecystectomy. Hemostasis was obtained after embolization of the right hepatic artery.
CASE REPORT A 40-year-old man was admitted in the emergency department for typical acute biliary cholangitis revealed by the triad of jaundice, fever, and right upper quadrant pain. Morphologic examinations showed an obstruction of the common bile duct due to stones. Endoscopic decompression (including endoscopic retrograde cholangiopancreatography followed by sphincterotomy) associated with the administration of parenteral antibiotics resulted in a favorable clinical course. Elective single-port cholecystectomy was performed 1 month later. The intraoperative exploration revealed macroscopic features of chronic cholecystitis. The dissection was difficult because of
FIGURE 1. Arterial-phase abdominal computed tomography showing dilated left and right hepatic ducts (red arrows) compressed by the hematoma containing aerial levels (red star). The ruptured pseudoaneurysm of the right hepatic artery is situated next to the clip (black arrow).
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015
Surg Laparosc Endosc Percutan Tech
Volume 25, Number 1, February 2015 Compressive Hematoma After Single-Port Cholecystectomy
edema and inflammation, but there was no need to convert or to add a port. The cystic artery originated directly from the right hepatic artery. No cholangiography was performed intraoperatively because of a narrow cystic duct lumen. The final pathologic examination showed xanthogranulomatous cholecystitis. The patient was readmitted on postoperative day 15 at the emergency department for persistent epigastric pain, vomiting, and jaundice. At the time of admission, the patient was not febrile and had no sign of hemodynamic instability. The physical examination showed epigastric and hypochondrium tenderness, hepatomegaly, and intense mucocutaneous icterus. The patient did not complain of hematemesis or melena. The blood test results showed an inflammatory syndrome (leukocytes: 12,730/mm3, C-reactive protein: 86.8 mg/L), anemia (hemoglobin: 10.8 g/dL), and moderate cholestasis with increased bilirubin (total bilirubin: 36 mmol/L, conjugated bilirubin: 16 mmol/L). In addition, the patient had elevated alkaline phosphatase (423 IU/L) and g-glutamyl transferase (515 IU/L) and cytolysis (alanine aminotransferase: 126 IU/L, aspartate aminotransferase: 100 IU/L). The prothrombin level, V-factor, and lipasemia were normal. An abdominal and pelvic computed tomography (CT) was performed in the emergency department, and it revealed an isolated large hematoma (72 60 40 mm) with aerial levels located in the gallbladder fossa and minor active bleeding from the right hepatic artery (Fig. 1). The common bile duct was compressed by the hematoma, and a dilatation of intrahepatic bile ducts was observed (Fig. 1). As a result, a compressive right hepatic artery pseudoaneurysm was suspected. The patient was immediately treated with parenteral antibiotic therapy consisting of piperacilin, tazobactam, and gentamicin. Selective celiac arteriography using a 5 Fr C2 Cobra catheter (Cook, Letchworth, Herts, UK) revealed a ruptured 7 mm diameter pseudoaneurysm arising from the right hepatic artery (Fig. 2) near the surgical clips. The right hepatic artery also presented an eroded aspect. The right hepatic artery was microcatheterized with a Progreat 2.7 Fr microcatheter (Progreat Microcatheter System, Terumo, Japan), and embolization was performed with helical hydrogel microcoils (AZUR Detachable Peripheral HydroCoils, Terumo, Japan). Control arteriography showed a complete exclusion of the pseudoaneurysm and the right hepatic artery (Fig. 3). The downstream bed was well vascularized by an accessory left
FIGURE 3. Selective common hepatic artery arteriography. Helical hydrogel microcoils (black star) are placed in the right hepatic artery. The left hepatic artery (black arrow) arises from the left gastric artery. hepatic artery arising from the left gastric artery. The patient’s postembolization recovery was uneventful with resolution of the jaundice and normalization of inflammatory signs, cytolysis, and bilirubin within 2 days and cholestasis within 1 month. A CT scan was performed 3 days after embolization, and it showed a regressing hematoma (50 47 25 mm), no active bleeding, and no hepatic ischemia. The patient was discharged 4 days after the procedure with a 15-day oral antibiotic treatment including ciprofloxacin and metronidazole. The CT scan performed 3 months after the embolization showed a complete resorption of the hematoma and no dilatation of the intrahepatic and extrahepatic bile ducts. There was also no liver necrosis and no recurrence of the pseudoaneurysm.
DISCUSSION
FIGURE 2. Selective celiac arteriography showing a ruptured pseudoaneurysm (red arrow) of the right hepatic artery. ALHA indicates accessory left hepatic artery; CHA, common hepatic artery, GA, gastroduodenal artery; LGA: left gastric artery; LHA, left hepatic artery; RHA, right hepatic artery.
Copyright
r
During laparoscopic procedures for gallbladder benign lithiasis pathologies, vascular injuries are less common than bile duct injuries, but they can be rapidly fatal.9 Multicenter studies have reported a rate of 0.25% for vascular injuries9 and a rate of 0.6% for hepatic artery pseudoaneurysms8 after conventional laparoscopic cholecystectomy. The symptoms usually appear in the early postoperative period but may be more delayed (7th to 120th postoperative day).6 The single-incision laparoscopic cholecystectomy emerged as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy.4 However, no trial was adequately powered to assess the safety of this technique,4 particularly with respect to vascular injuries. Moreover, this case of pseudoaneurysm of the right hepatic artery after single-port cholecystectomy is the first reported in the literature. The causes of hepatic artery pseudoaneurysms after cholecystectomy may include direct vascular direct trauma, vascular erosion caused by bile contact, and local inflammatory reactions in cases of pancreatitis, cholecystitis, or angiocholitis.10,11 The exact mechanisms of this process are not well understood. This case demonstrated that it is difficult to identify the cause of pseudoaneurysm occurrence retrospectively. However, contributing factors that can explain vascular trauma are usually identified, including a direct lesion of the vascular wall, thermal diffusion through
2014 Wolters Kluwer Health, Inc. All rights reserved.
www.surgical-laparoscopy.com |
e43
Surg Laparosc Endosc Percutan Tech
Abdalla et al
metallic clips placed close to the vascular pedicle,12 vascular erosion due to clip encroachment, or slipping of the surgical clip applied to the cystic artery.13 In addition, anatomic variations and technical difficulties may also explain vascular and bile duct injuries during laparoscopic cholecystectomy. During single-port laparoscopic cholecystectomy, the absence of triangulation makes the use of instruments for suction/irrigation and diathermy more difficult, which can result in less accurate hemostasis than with traditional laparoscopic techniques. The ergonomic limitation due to the versatility of the instruments may lead to an imprecise dissection, especially during detachment of the gallbladder from its hepatic bed.4 In our case, the patient presented with right upper quadrant pain and isolated obstructive jaundice. The first diagnostic hypothesis was a bile duct injury because no intraoperative cholangiography was performed during cholecystectomy. The CT scan was useful in determining the diagnosis of compressive hematoma on the common bile duct due to a ruptured right hepatic artery pseudoaneurysm. Given the recent history of angiocholitis, biological inflammatory signs and images of aerial levels on the gallbladder bed, we suspected an infected hematoma. As a result, we initiated broad-spectrum antibiotic therapy. We chose not to drain the hematoma because the coil embolization was immediately effective. A magnetic resonance cholangiography was not performed because the CT scan led to an accurate diagnosis. However, this examination could have been discussed as a bile duct injury was suspected.14 Arterioembolization has become the first choice of treatment for isolated vascular injuries after laparoscopic cholecystectomy.8 When the intra-arterial approach is not feasible because of abnormal portal flow or surgical hepatic artery ligature, direct transhepatic embolization of the right hepatic artery can be performed with high success rates.7 A surgical approach is indicated when embolization fails or when the proper expertise is not available.7 In our case, selective embolization of the pseudoaneurysm instead of the right hepatic artery could have been discussed. Although the latter option is safe and rarely followed by liver necrosis, there is a risk of pseudoaneurysm recanalization. This outcome is explained by the numerous collaterals that permeabilize after major artery occlusion. Conversely, perprocedure aneurysm rupture is more likely to occur when selective pseudoaneurysm embolization is performed.
CONCLUSIONS A compressive pseudoaneurysm of the right hepatic artery is a rare vascular complication that should be considered in cases of postoperative obstructive jaundice after laparoscopic cholecystectomy. Single-port laparoscopic
e44 | www.surgical-laparoscopy.com
Volume 25, Number 1, February 2015
cholecystectomy is technically demanding, which makes it a potential cause of vascular lesions. In our experience, endovascular management by coil embolization is a noninvasive and effective treatment for ruptured pseudoaneurysms.
REFERENCES 1. Gallstones and laparoscopic cholecystectomy. NIH Consens. Statement 1992;10:1–28. 2. Sarno G, Al-Sarira AA, Ghaneh P, et al. Cholecystectomyrelated bile duct and vasculobiliary injuries. Br J Surg. 2012;99:1129–1136. 3. Paganini A, Lomonto D, Navordino M. One port laparoscopic cholecystectomy in selected patients. Third International Congress on New Technology in Surgery. Luxemburg, 1995. 4. Trastulli S, Cirocchi R, Desiderio J, et al. Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conventional laparoscopic cholecystectomy. Br J Surg. 2013;100:191–208. 5. Chen C-C, Chen B-B, Wang H-P. Upper gastrointestinal bleeding owing to right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy. Gastroenterology. 2009;137:5–6. 6. Balsara KP, Dubash C, Shah CR. Pseudoaneurysm of the hepatic artery along with common bile duct injury following laparoscopic cholecystectomy. A report of two cases. Surg Endosc. 1998;12:276–277. 7. Chigot V, Lallier M, Alvarez F, et al. Hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. Pediatr Radiol. 2003;33:24–26. 8. Nicholson T, Travis S, Ettles D, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol. 1999; 22:20–24. 9. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165:9–14. 10. Ahmed I, Tanveer UH, Sajjad Z, et al. Cystic artery pseudoaneurysm: a complication of xanthogranulomatous cholecystitis. Br J Radiol. 2010;83:165–167. 11. Parthenis DG, Skevis K, Stathopoulos V, et al. Postlaparoscopic iatrogenic pseudoaneurysms of the arteries of the peritoneal and retroperitoneal space: case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2009;19:90–97. 12. Hewes JC, Baroni ML, Krissat J, et al. An unusual presentation of hepatic aneurysm as a complication of laparoscopic cholecystectomy. Eur J Surg Acta Chir. 2002; 168:566–568. 13. Halbe S, Ahmed NI, Sundar K, et al. Pseudoaneurysm in gall bladder fossa following laparoscopic cholecystectomy. Indian J Gastroenterol. 1999;18:122. 14. Mazziotti S, Blandino A, Gaeta M, et al. Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings. Abdom Imaging. 2003;28:835–837.
Copyright
r
2014 Wolters Kluwer Health, Inc. All rights reserved.
