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Since the introduction of laparo-scopic cholecystectomy muchattention has been drawn to the

occurrence of iatrogenic injuries tothe major bile ducts during this pro-cedure. Less well described are iatro-genic injuries to the hepatic or cysticarteries, which can occur in isolationor in association with bile-duct in-juries. In this report we describe anunusual vascular injury that was asso-ciated with trauma to the common

hepatic duct. The arterial injurycaused massive gastrointestinal bleed-ing several weeks after the patient’sinitial hospital discharge.

CASE REPORT

A 49-year-old woman underwentelective laparoscopic cholecystectomyfor symptomatic cholelithiasis. Reviewof the operative report indicated thatdissection of the hepatocystic triangle

had been carried out bluntly withoutelectrocautery. The dissection hadbeen difficult because of fibrosis in thetriangle, and a small transverse tear inthe common hepatic duct had beencreated and recognized. The cysticartery was described as crossing thetriangle in the usual position, and ithad been clipped and divided. Nomention was made of intraoperativehemorrhage. The cystic duct had beenidentified and divided, and after re-

Case ReportÉtude de cas

HEMOBILIA COMPLICATING ELECTIVE LAPAROSCOPICCHOLECYSTECTOMY: A CASE REPORT

Jean-Denis Yelle, MD, FRCSC; Robert Fairfull-Smith, MD, FRCSC; Pasteur Rasuli, MD, FRCPC; John W. Lorimer, MD, FRCSC

From the Department of Surgery, Ottawa General Hospital, Ottawa, Ont.

Accepted for publication Apr. 24, 1995

Correspondence and reprint requests to: Dr. John W. Lorimer, Rm. K-11, Ottawa General Hospital, 501 Smyth Rd., Ottawa ON K1H 8L6

Iatrogenic injury to the hepatic or cystic arteries can occur during laparoscopic cholecystectomy and can beseen in isolation or in association with bile-duct injury. The most common manifestation of arterial injuryis intraoperative hemorrhage; also, interruption of the right hepatic artery can occur without hemorrhage,and this can be clinically insignificant or associated with hepatic ischemia. A less common manifestation ofarterial injury during laparoscopic cholecystectomy is presented. A 48-year-old woman had a pseudoa-neurysm of the major anterior branch of the right hepatic artery in association with an injury to the com-mon hepatic duct. This complication presented as massive hemobilia after she had been discharged fromthe hospital. Definitive repair of the pseudoaneurysm was carried out at the time of Roux-en-Y hepaticoje-junostomy for correction of the associated duct injury. This unusual vascular complication should be con-sidered in patients after laparoscopic cholecystectomy who demonstrate evidence of late occult or obvioushemorrhage.

Une cholécystectomie par laparoscopie peut provoquer une atteinte iatrogène des artères hépatique ou cys-tique qui peut être présente seule ou liée à une atteinte des canaux biliaires. L’hémorragie peropératoire estle signe le plus fréquent d’une atteinte des artères. Il peut aussi y avoir occlusion de l’artère hépatique droitesans hémorragie, ce qui peut n’avoir aucune importance sur le plan clinique ou être lié à une ischémie hépa-tique. Les auteurs présentent une manifestation moins fréquente d’une atteinte de l’artère au cours d’unecholécystectomie par laparoscopie. Une femme de 48 ans avait un pseudo-anévrisme de la branche an-térieure majeure de l’artère hépatique droite liée à une atteinte du cholédoque. Cette complication a pris laforme d’une hémobilie massive après sa libération de l’hôpital. On a procédé à une réparation définitive dupseudo-anévrisme au cours d’une hépaticojéjunostomie de Roux-en-Y qui visait à corriger l’atteinte connexedu canal. Il faut envisager cette complication vasculaire inusitée chez les patients qui ont subi une cholécys-tectomie par laparoscopie et qui présentent des signes d’hémorragie évidente ou occulte tardive.

moval of the gallbladder the tear inthe common hepatic duct was man-aged by enlarging the hepati-codochotomy and inserting a 10-French T tube. The tube was suturedinto the duct, and the procedure wasconsidered satisfactory on a postinser-tion T-tube cholangiogram. The tubewas removed 2 weeks postoperativelyafter another satisfactory cholan-giogram had been obtained.One week later she was admitted to

a second hospital with acute, severeupper abdominal pain followed bymassive hematemesis and melena. Shewas hemodynamically unstable and re-quired 4 units of packed red bloodcells and urgent operation. At surgery,copious bleeding from the area of theporta hepatis was seen. This was con-trolled by a Pringle manoeuvre and a

single absorbable pin-stitch placed inwhat was believed to be a small lateraldefect in the proper hepatic artery. Ar-terial pulsation in the hepatoduodenalligament was preserved, and a drainwas inserted. Postoperatively an exter-nal biliary fistula developed throughthis drain, with loss of 500 mL/d ofbile. Three weeks after her second op-eration she again experienced severeupper abdominal pain, and this wasfollowed by external hemorrhagethrough the opening of the biliary fis-tula (which had been extubated bythen). She was then transferred to ourhospital for further management.On arrival she was hemodynami-

cally stable and had an obvious exter-nal biliary fistula. Small amounts ofblood were episodically dischargedinto the fistula. There was no evidence

of systemic infection. A contrast studyof the fistula showed filling only of theright and left hepatic ducts, and an en-doscopic retrograde cholangiogramdemonstrated a very tight stricture ofthe common hepatic duct extendingfor 2.5 cm. in length. A selective he-patic arteriogram showed a pseudoa-neurysm of the major anterior branchof the right hepatic artery, and therewas a surgical clip in close proximityto this abnormality (Fig. 1). No cysticartery was identified on this arteri-ogram. At operation, after obtainingproximal control of the hepatic artery,the hematoma was evacuated andbleeding points were carefully over-sewn with nonabsorbable material. ARoux-en-Y jejunal loop was anasto-mosed to the hepatic ducts at the levelof the bifurcation. Six months afterthe third operation, biochemical indi-cators of liver function were normaland biliary drainage was normal, asdemonstrated by HIDA scintigraphy.

DISCUSSION

Injury to the bile ducts has longbeen known to be a potential compli-cation of removal of the gallbladder.This has become a particular concernduring the laparoscopic era.1,2 Muchless attention has been paid to vascu-lar damage occurring at cholecystec-tomy, but in a large referred series ofbile-duct injuries,3 simultaneous vas-cular injuries had occurred in about25% of cases, and it was concludedthat ductal damage often followed at-tempts to control bleeding. Most vas-cular injuries involve the right hepaticartery or cystic artery branches, and in-juries to the portal circulation aremuch less common. Reports of bile-duct injury after laparoscopic chole-cystectomy continue to indicate a highfrequency of associated vascular dam-age, particularly to the right hepaticartery.4 In fact, the combined injury of

HEMOBILIA AFTER LAPAROSCOPIC CHOLECYSTECTOMY

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FIG. 1. Selective hepatic arteriogram demonstrating origin of pseudoaneurysm from injury to majoranterior branch of right hepatic artery (upper arrow) and pseudoaneurysm itself (lower arrow) inclose proximity to surgical clip.

YELLE ET AL

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bile-duct transection with partial exci-sion of the extrahepatic ducts and in-jury to the right hepatic artery hasbeen considered to be the “classic in-jury” seen with laparoscopic cholecys-tectomy.5

Probably the most common mani-festation of arterial injury duringcholecystectomy is intraoperative he-morrhage. In the hepatocystic trianglethe right hepatic artery can be misiden-tified as the cystic artery and damaged;this is most likely to occur with a“looping” vessel travelling nearly par-allel to the cystic duct. This anatomicsituation is often associated with a veryshort cystic artery.6,7 Other potentialsources of difficulty leading to cysticartery hemorrhage include the pres-ence of a low-lying or “inferior” vesseloutside the triangle or the presence ofa double artery.6,7 A single cystic arterythat bifurcates early can have the samepotential for hemorrhage as a doublevessel, because ligation of the firstbranch can be followed by injury tothe more posterior one.Less commonly, arterial injury in-

volves occlusion of the right hepaticartery without intraoperative hemor-rhage. Because such an injury may beclinically insignificant, the true inci-dence is difficult to determine,8 but atleast some cases result in hepatic is-chemia.4

We believe that the third and leastcommon manifestation of arterial in-jury is delayed bleeding originatingfrom a pseudoaneurysm. Reports inthe literature are in the form of singlecases and have described origin fromthe cystic9 and hepatic3,10 arteries.Most cases of hemobilia result from

parenchymal disorders of the liver, butabout 10% are from vascular lesions.These are usually hepatic arteryaneurysms,11 and a minority of theseare pseudoaneurysms. About half ofthese aneurysms ultimately decom-

press into the bile ducts.9 In the casereported here, the rupture occurredthrough the original common hepatic-duct injury, but decompression intothe cystic-duct stump has also beendescribed.9 The precise mechanism ofinjury in our case remains obscure, be-cause there was no trace of the cysticartery on the arteriogram, but becauseof the proximity of a surgical clip tothe abnormality, we assume that themajor anterior branch of the right he-patic artery was either misidentified asthe cystic artery or injured in theprocess of occluding this artery.Conversion to open cholecystec-

tomy can be required for control ofintraoperative hemorrhage, but suchan injury does not generally cause di-agnostic difficulty. Arterial interrup-tion without hemorrhage is often clin-ically insignificant, and it is unlikely tocome to attention unless there hasbeen a simultaneous bile-duct injury.A pseudoaneurysm of the hepatic orcystic arteries is clearly rare after la-paroscopic cholecystectomy, but thisdiagnosis should be considered in pa-tients who present after an intervalwith pain and either anemia or gas-trointestinal hemorrhage. Ultrasonog-raphy, particularly with colour-flowDoppler scanning, can help to iden-tify a pseudoaneurysm in this area,9,12

but generally selective arteriographywill be necessary. Transcatheter em-bolization has been described as de-finitive treatment,9 but in our casesince repair of the associated duct in-jury was also required, we decided toobliterate the pseudoaneurysm duringan open surgical procedure.

References

1. Rossi RL, Schirmer WJ, Braash JW etal: Laparoscopic bile duct injuries:risk factors, recognition and repair.Arch Surg 1992; 127: 596–602

2. Bernard HR, Hartman TW: Compli-cations after laparoscopic cholecys-tectomy. Am J Surg 1993; 165:533–535

3. Blumgart LH, Kelley CJ, BenjaminIS: Benign bile duct strictures follow-ing cholecystectomy: critical factorsin management. Br J Surg 1984; 71:836–843

4. Madariaga JR, Dodson SF, Selby R etal: Corrective treatment andanatomic considerations for laparo-scopic cholecystectomy injuries. J AmColl Surg 1994; 179: 321–325

5. Branum G, Schmitt C, Baillie J et al:Management of major biliary compli-cations after laparoscopic cholecys-tectomy. Ann Surg 1993; 217:532–541

6. Hugh TB, Kelly MD, Li B: Laparo-scopic anatomy of the cystic artery.Am J Surg 1992; 163: 593–595

7. Merenstein D, MacGowan KM,Kune GA: Frequency of anatomichazards during cholecystectomy. DigSurg 1985; 2: 121–125

8. Halasz NA: Cholecystectomy and he-patic artery injuries. Arch Surg 1991;126: 137–138

9. Clements WD, Wilson RH, CrothersJG et al: Pseudoaneurysm of the cys-tic artery following cholecystectomy.J R Coll Surg Edinb 1993; 38:348–349

10. Thomas WE, May RE: Hepatic arteryaneurysm following cholecystectomy.Postgrad Med J 1981; 57: 393–395

11. Katz PO, Salas L: Less frequentcauses of upper gastrointestinalbleeding. Gastroenterol Clin NorthAm 1993; 22: 875–889

12. Barba CA, Bret PM, Hinchey EJ:Pseudoaneurysm of the cystic artery:a rare cause of hemobilia. Can J Surg1994; 37: 64–66