Laparoscopic Management of a Right Posterior Portal Vein Injury During Cholecystectomy

Abstract

Introduction:

Laparoscopic cholecystectomy is the gold standard treatment for acute calculous cholecystitis. Vascular injuries are uncommon but potentially devastating complications. The exact incidence of postcholecystectomy vascular injuries remains unknown, in particular the risk of portal vein lesion is seldom described. Some series report up to 7% vascular injuries in autopsy of patients who underwent open cholecystectomy. ¹ However, in patients with associated common bile duct injury, the incidence is higher, ranging from 12% to 39%. ² Uncontrollable bleeding during laparoscopic cholecystectomy might occur in up to 1.9% of all procedures, leading to conversion to open surgery in up to 2% of cases. ³ This video illustrates that laparoscopic management of portal vein injury during cholecystectomy is feasible.

Materials and Methods:

An 89-year-old male patient, known for ischemic heart disease and chronic renal failure, was admitted for a cholecystectomy. He presented with acute episode of calculous cholecystitis 6 months before surgery, treated by antibiotics and a percutaneous drainage, as well as a choledocholithiasis 3 months later that was effectively managed with an endoscopic retrograde cholangiopancreatography. During surgery, adhesiolysis between the gallbladder and the duodenum was performed initially. Calot's triangle dissection was difficult because of a chronic hepatic pedicle inflammation and a scarred and atrophic gallbladder. During the dissection, posterior to Calot's triangle, major venous bleeding occurred. The bleeding was temporarily controlled with a grasper that allowed the cholecystectomy to be completed. Once the gallbladder was removed, the surgical site was explored, finding a lesion on a right posterior branch of the portal vein. The bleeding was managed laparoscopically. Two bulldog clamps were placed on both sides of the vascular lesion to identify an anterior wall defect that measured 2 mm in diameter. The wall defect was sutured with a nonabsorbable 6-0 monofilament suture. Hemostasis was achieved and intraoperative ultrasonography showed a normal flow of the right portal vein and artery at the end of the procedure.

Results:

The postoperative course was marked by a cytolysis that resolved spontaneously. Hepatic ultrasonography showed a partial thrombosis of the right posterior portal vein branch, with a patent right hepatic artery before the patient's discharge. The patient underwent 3 months treatment with acenocoumarol with an uneventful follow-up.

Conclusion:

Hepatic pedicle inflammation associated with severe cholecystitis can lead to portal vein injury during delayed cholecystectomy. The management of a portal vein lesion during cholecystectomy is feasible by minimal invasive techniques with satisfactory results.

No competing financial interests exist.

Runtime of video: 8 mins 18 secs

Consentement:

Written informed consent was obtained from the patient. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

This video was presented at the Swiss Surgery Annual Congress on June 2021 but has not been published, accepted for publication, or under editorial review for publication elsewhere.