Hepatic vein injury during laparoscopic cholecystectomy: The unappreciated proximity of the middle hepatic vein to the gallbladder bed

Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter=2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage.     

Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy

BACKGROUND: Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS: Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS: Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS: Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.     

Role of preoperative color doppler ultrasound scan in the evaluation of the risk of injury of major branches of the middle hepatic vein during laparoscopic cholecystectomy

During laparoscopic cholecystectomy, the separation of the gallbladder from the liver bed may sometimes cause severe hemorrhages. One reason for severe hemorrhages may be injury to the major branches of the middle hepatic vein (MHV), which may be too close or adherent to the gallbladder. In our institutional experience of 798 laparoscopic cholecystectomies, no major hemorrhage from the gallbladder bed has been encountered. The aim of this prospective study was to investigate the relationship between the major branches of the MHV and the gallbladder bed in our patients. We measured the distance of the closest branches of the MHV from the gallbladder bed by color Doppler ultrasound scan. The mean and the median distances of the closest branch of the MHV to the gallbladder was found to be 17.4 +/- 6.2 mm and 17.7 mm, respectively (range, 6-29.1 mm). In conclusion, the distance of the closest branch of the MHV to the gallbladder bed in our patient population seems to allow for a safe laparoscopic cholecystectomy.     

Laparoscopic anatomy of the cystic artery.

Uncontrolled arterial bleeding during laparoscopic cholecystectomy is a serious problem and may increase the risk of bile duct damage. Therefore, accurate identification of the anatomy of the cystic artery is important. We reviewed the anatomy of the cystic artery and its variations as seen through the video laparoscope. A "normal" cystic artery was found in only 72% of patients. The most important laparoscopically noted variations were doubling of the cystic artery (22%) and an artery that ran inferior to the cystic duct (6%). Small branches of the cystic artery, which we suggest be named Calot's arteries, supply the cystic duct and may cause troublesome bleeding during laparoscopic dissection in the hepatobiliary triangle. A scissor dissection technique was found most useful for identifying the arterial anatomy. Careful identification of arterial anomalies should help to reduce the incidence of bile duct injuries during laparoscopic cholecystectomy.     

腹腔镜胆囊切除术中肝中静脉分支损伤的危险性因素分析

目的探讨腹腔镜胆囊切除术中胆囊床出血的原因.方法对从2000年9月到2001年3月接受腹腔镜胆囊切除手术的617例中1例患者中,随机选取其中91例进行前瞻性分析,并对617例发生胆囊床出血的病例进行回顾性分析.结果多普勒超声检查均发现有1根肝中静脉的重要分支从胆囊床后面通过,该血管离胆囊床的最近距离点(C点)到胆囊的平均距离为(5.0±4.6)mm,其中15.4%(14例)肝中静脉是直接和胆囊床相贴,11.0%(10例)和胆囊床的距离在1mm以内,C点的内径为(3.2±1.1)mm;约有34.7%(31例)C点位于胆囊纵轴左侧,位于右侧的有39例(42.9%),正好落在胆囊纵轴上的有21例(23.1%).C点肝静脉的流速为(9.9±3.3)cm/s.结论肝中静脉最靠近胆囊点,较多会出现在胆囊纵轴的右侧.建议在术前,尤其是在腹腔镜胆囊切除术前进行常规的多普勒超声检查,以明确肝中静脉和胆囊床的关系,高度重视肝中静脉和胆囊床直接相贴的病例.     

腹腔镜胆囊切除术中肝中静脉属支损伤的预防及处理

腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中手术区域的出血是困扰外科医生的一个重要问题.除了胆囊动脉破裂之外,由胆囊床引发的出血也是LC术中常见的出血原因之一,而其中位于胆囊床后方肝中静脉属支的破裂所导致的胆囊床出血则更是术中非常棘手的问题,这不仅会使原本简单的手术复杂化,模糊手术区域的解剖结构,还往往可导致严重的手术并发症,是构成Lc术中转开腹的主要因素之一.本文就肝中静脉属支的局部解剖、损伤后的处理及损伤的预防进行综述.     

胆囊后三角应用解剖及其在腹腔镜胆囊切除术中的临床意义

目的探索胆囊后三角的解剖结构,为腹腔镜胆囊切除术提供胆囊后三角解剖学基础。方法2005年9月至2008年1月山东省泰安卫生学校、山东省立医院、泰山医学院附属医院、荣成市人民医院选用81例成人尸体标本,模拟腹腔镜胆囊切除术胆囊后三角入路,观察胆囊后三角的组成边界、穿行结构及毗邻关系。结果胆囊后三角由胆囊颈部后壁、胆囊管、胆总管上段和肝右叶脏面组成;胆囊管的长度(3018±219)mm,直径为(302±036)mm,其形状有直线型和弯曲型;胆囊动脉的直径为(168±035)mm;胆囊管较胆囊动脉粗,二者差异有统计学意义（P＜005）;6例（74%）于胆囊后三角后下方见异常胆囊动脉,自胆囊颈及胆囊体后方入胆囊,胆囊动脉自胆囊管后方走行进入胆囊8例（99%）,胆囊动脉走行于胆囊管前方5例（61%）;5例（61%）发自肝右叶脏面的副肝管通过胆囊后三角经胆囊管和肝总管汇合处后下方入胆总管。结论熟悉胆囊后三角的组成结构及毗邻关系,是避免手术时损伤血管和胆管的关键,对腹腔镜胆囊切除术的开展具有指导意义。     

腹腔镜胆囊切除术

Trocar采用“四孔法”布局。体位采用仰卧位,穿刺后头高足低30°,向左倾斜10°~15°。探查完毕后,可见胆囊大小约9 cm×3 cm×3 cm,与周围组织无粘连。助手无创钳下压网膜,术者左手提起胆囊,右手分离胆囊三角,钝性游离胆囊颈管和胆囊动脉,可见胆囊颈管直径约0.2 cm,胆总管直径约0.7 cm,肝右动脉发出胆囊动脉前后支。可吸收夹夹闭胆囊颈管及胆囊动脉,并切断,将胆囊从胆囊床剥离。自剑突下Trocar孔取出胆囊。电烙胆囊床,确认无活动性渗血后清点纱布、撤出腔镜器械。     

Laparoscopic subtotal cholecystectomy: a review of 56 procedures

BACKGROUND AND PURPOSE: The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1,680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy. PATIENTS AND METHODS: In 56 of 1,680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present in 32 patients; 12 patients had Mirizzi syndrome, 6 patients had a sessile gallbladder, and 6 patients had a gangrenous gallbladder. The Endo-GIA 30 stapler was used in 40 patients, sequential clips were used in 9 patients, and a suture for stump closure was used in 5 patients. A subhepatic drain was inserted in 50 patients. RESULTS: Two conversions to open surgery were needed because of gangrene of the gall bladder wall and one conversion as a result of continued bleeding from the cystic artery after application of the Endo-GIA 30 stapler. The mean postoperative stay in hospital was 2.5 days. One patient had a solitary bile duct calculus extracted at endoscopic retrograde cholangiopancreatography 3 months after surgery. Three patients had biliary drainage that lasted for a week, and four patients had epigastric port-site infections that resolved with antibiotics, dressings and postural drainage. CONCLUSION: Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult cholecystectomies.     

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??Applied anatomy of posterior Calot’s triangle and its clinical significance in laparoscopic cholecystectomyYOU Xiao??gong*,SHI Bao??min,JING Li??yan,et al.*Taian Health School of Shandong Province??Taian 271000,China Corresponding author??SHI Bao??min??E??mail:tawxyxg@163.com AbstractObjectiveTo investigate the structure of the posterior Calot's triangle sector and provide anatomic data of posterior Calot's triangle for laparoscopic cholecystectomy.MethodsFrom September 2005 to January 2008,the structure of posterior Calot’s triangle was observed by simulating the posterior Calot’s triangle approach of laparoscopic cholecystectomy in 81 samples of adult liver and gallbladder.ResultsPosterior Calot’s triangle was composed of the back wall of gallbladder neck,cystic duct,the upper section of common bile duct, and the facies visceralis of lobus hepatis dexter.The length of the ductus cysticus was (30??18±2??19)mm and (3??02±0??36)mm in diameter(range from 2??32 to 3??98mm).It had either linear type or arcuate type.The mean diameter of the cystic artery was (1??68±0??35) mm (range from 0??80 to 3??78mm). Abnormality of cystic artery was observed posterosuperior to the posterior Calot’s triangle in 6 sample (7??4%) entering gallbladder from the back of neck and body of gallbladder.Cystic artery pass through the back of the cystic duct occurred in 8 samples (9??9%).Cystic artery pass through the front of the cystic duct occurred in 5 samples(6.1%).Accessory hepatic duct originated in the facies visceralis of lobus hepatis dexter was observed in 5 samples??6??1%??through the posterior Calot’s triangle entering common hepatic duct through the joint of cystic duct and common hepatic duct.ConclusionIdentification of posterior Calot's triangle and its bordering structures is beneficial to avoiding injuries of surrounding blood vessels and bile ducts during laparoscopic cholecystectomy     

The influence of intraoperative complications on adhesion formation during laparoscopic and conventional cholecystectomy in an animal model

BACKGROUND: The aim of this study was to evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy. MATERIALS AND METHODS: Qualified surgeons performed 60 experimental laparoscopic cholecystectomies (LC) in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, laceration of the liver bed, or gallbladder perforation) and the formation of adhesions, surviving animals were divided into four groups according to the type of complication occurred. Assessment of the results was made by second-look laparoscopy 4 weeks after LC using the adhesion index (AI; score range, 0-4). The animals then were killed so the extent of adhesion formation could be measured. As a control, open cholecystectomy was performed in 15 dogs without intraoperative complications. The Mann-Whitney rank-sum test and Dunn's method were used for statistical analysis. RESULTS: No adhesion formation or intraoperative complications were registered in the laparoscopic group I. In all the cases wherein bleeding or laceration of the liver bed occurred and was managed with electrocoagulation, adhesions formed. Adhesion formation in these groups was significantly higher than in "ideal LC" or cases of gallbladder perforation alone (p < 0.01). All the animals in the control group developed significantly more adhesions than those in the experimental group (p < 0.05). CONCLUSIONS: It seems that LC has a lower rate of adhesion formation than the conventional open technique. Complications such as bleeding or laceration of the liver bed during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation to gallbladder perforation during LC.     

Color Doppler Ultrasound Detection and Classification of the Tangential Hepatic Vein before Laparoscopic Cholecystectomy

Background: Unexpected fatal bleeding from the gallbladder bed during laparoscopic cholecystectomy is often associated with injury to the middle hepatic vein. This paper studies whether preoperative color Doppler ultrasound is effective in reducing the risk of injury. Also a venous classification is suggested. Methods: Between June 1999 and February 2004, 2,146 patients undergoing laparoscopic cholecystectomy by standard method received preoperative color Doppler ultrasound examinations. The closest distance between the hepatic vein and the gallbladder was studied. Also, cases of liver cirrhosis, number of conversions to open cholecystectomy, intraoperative blood loss, operative time, complications, and hospital stay were recorded (group D). At the end of the study, we retrospectively reviewed the same parameter of another 2,146 patients who received laparoscopic cholecystectomy without preoperative color Doppler ultrasound between the period of March 1995 and June 1999 (group ND). Results: In group D, 108 patients had cirrhosis. Four hundred and ninety-six patients (27 cases of cirrhosis) had a closest distance of 1 mm or less between the vein and the gallbladder. There were two conversions to open cholecystectomy, but none related to gallbladder bed bleeding. In group ND, there were five conversions, including four cases of gallbladder bed bleeding from the middle hepatic vein and one case of severe adhesion. The conversion rate was significantly higher. In group ND, the mean intraoperative blood loss in the cases of liver cirrhosis was significantly greater. Also, the operative time of patients with the closest vein and gallbladder distance of 1 mm or less in group D was significantly longer. Conclusions: Color Doppler ultrasound is an effective method for detecting the presence of potential bleeders. Although the operative time will be a bit longer, the operation can be done under meticulous care and complete preparation, so that the conversion rate and the risk of fatal hemorrhage can be reduced, especially in patients with liver cirrhosis.     

Hydrodissection with adrenaline–lidocaine–saline solution in laparoscopic cholecystectomy

Aim This investigation examined the effects of a solution injected to the gallbladder bed on operative time, bleeding, incidence of gallbladder perforation, and postoperative pain.Methods One hundred sixty-four consecutive patients with cholelithiasis were randomized into two clinically comparable groups. In group 1 (84 patients), 40 ml of saline–adrenaline–lidocaine solution was injected between the gallbladder and liver. In group 2 (80 patients), laparoscopic cholecystectomy was performed without hydrodissection. The time taken to dissect the gallbladder from the liver, bleeding from the liver bed, incidence of gallbladder perforation and spillage of bile and stones, duration of operation, amount of gas used for the laparoscopic cholecystectomy, conversion to open cholecystectomy, postoperative pain and pain localization were recorded.Results The mean dissection time, amount of gas used, incidence of gallbladder perforation, spillage of stones, and liver bed bleeding were not significantly different between the groups. There also was no significant difference between the groups regarding postoperative pain and pain localization.Conclusion Hydrodissection did not reduce time to dissect the gallbladder from the liver or risk of gallbladder perforation. Similarly, adrenaline and lidocaine injection between the gallbladder and the liver did not effect bleeding from the dissection area and did not alter postoperative pain or pain localization.     

经脐入路腹腔镜胆囊切除术的实验研究

目的探讨用三通道套管技术进行经脐入路腹腔镜胆囊切除术的可行性。方法8只家猪用三通道套管技术行经脐入路腹腔镜胆囊切除术。脐部置入三通道套管,经操作通道置入5mm腹腔镜和两只软性器械进行操作。右肋下置入微型抓钳抓持胆囊底,协助显露。用软性电凝钩分离胆囊管和胆囊动脉,内镜止血夹夹闭后切断。切除之标本自脐部切口取出。结果8只动物均顺利完成手术。无术中出血及术后并发症发生。手术时间1.5～2.5h,并随技术熟练而缩短。术后活检见胆囊管夹闭牢靠,未见胆漏和脓肿形成。结论经脐入路腹腔镜胆囊切除技术上是可行的,可以达到更加微创、以及腹壁无瘢痕的效果。     

腹腔镜胆囊切除术中胆囊动脉出血的预防及处理

目的探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中胆囊动脉出血的原因、预防及处理心得。方法 2000年2月～2012年8月实施LC 11 886例,其中146例(1.2%)术中发生胆囊动脉不同程度出血,通过钛夹夹闭、电灼、压迫止血。结果 144例成功完成LC,手术时间30～90 min,平均48 min;术中出血量200～500 ml,平均325 ml;无输血。中转开腹2例,1例胆囊动脉主干回缩至肝总管后方,无法施夹;1例合并肝硬化,胆囊床广泛渗血不止,系损伤肝中静脉的属支。146例术后随访3～6个月,平均4个月,未出现肝内外胆管损伤、继发出血、腹腔感染、肠梗阻等严重并发症。结论 LC术中胆囊动脉出血重在预防,一旦发生出血,应沉着、冷静,只要解剖结构熟悉,操作技术娴熟,选择合理的止血方法,胆囊动脉出血均能获得满意效果。     

腹腔镜胆囊切除术中出血的防治体会

目的探讨腹腔镜胆囊切除术中出血的原因及其防治措施。方法对我院1995年5月-2007年8月1330例腹腔镜胆囊切除术的临床资料进行回顾性分析。结果本组所有出血病例术中均得到了有效控制。无术中因难以控制的大出血致中转开腹者，无术后继发出血者，无术中因止血致胆管损伤者。结论胆囊动脉和胆囊床出血的正确处理是减少和避免术中、术后出血的关键。     

Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.     

Fistula between cystic artery pseudoaneurysm and cystic bile duct cause of acute anemia one year after laparoscopic cholecystectomy

We present a case of hemorrhage from a cystic artery pseudoaneurysm one year after laparoscopic cholecystectomy. A 78-year-old male with a history of recurrent melena, hematemesis, and right upper abdominal pain was admitted to our emergency department. His blood pressure was 60/30 mm Hg with a pulse rate of 100 beats per minute. Hemoglobin was 7.6 g/dL and white blood cell count 19500/mm(3). Computed tomography scan of the abdomen and selective digital subtraction arteriography showed a pseudoaneurysm in the region of the former bed of the gallbladder. During gastroscopy, a pulsatile bleeding out of the papilla of Vater was found. Surgery by the open approach confirmed the presence of a cystic artery pseudoaneurysm and showed an additional fistula between the pseudoaneurysm and the cystic bile duct. Resection of the pseudoaneurysm and revision of the common bile duct with implantation of a T-tube was performed. The patient recovered well and was discharged from our hospital three weeks after surgery.     

Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: Report of a case

A 63-year-old woman was admitted for cholecystitis and underwent a laparoscopic cholecystectomy (LC). She experienced abdominal pain and hemobilia 11 days after the LC. Angiography was performed but it did not show any source of bleeding. Thereafter, at 27 days after LC, a repeat angiogram was performed which revealed a pseudoaneurysm (PA) arising from a cystic artery stump and an embolized PA sack. However, another PA arising from near the embolized PA and liver abscess was observed 4 days after embolization. The arterial collateral flow was evaluated by endovascular balloon occlusion of the right hepatic artery and it was embolized proximal and distal to the bleeding point. The embolization of the partial hepatic artery was effective for PA when packing the PA sack proved to be insufficient. In patients with liver cirrhosis or liver abscess who require an adequate arterial liver flow, it is important to evaluate the collateral arterial flow before hepatic artery embolization.     

腹腔镜胆囊切除术中胆囊动脉出血的处理

目的探讨腹腔镜胆囊切除术中预防和处理胆囊动脉出血的临床经验。方法回顾性分析我院2002年1月至2007年12月收治的行腹腔镜胆囊切除术术中发生胆囊动脉出血138例的临床资料。结果本组腹腔镜下处理胆囊动脉出血83例,中转开腹7例,中转率为8．43％;发生胆道损伤3例,失血性休克1例。直接转开腹55例,无胆道损伤等严重并发症者。结论只要遵循耐心压迫止血、吸尽积血后再钳夹、电凝的处理原则,大部分胆囊动脉出血是能够在腹腔镜下得到控制的;及时中转开腹,能较好的避免血管和胆道损伤。