Introduction

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Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Despite its many advantages when compared to open procedure, there is an increase in the incidence of 0.3%-1.0% [1, 2] of biliary and vascular injuries. Hepatic artery pseudoaneurysm is a rare but serious complication associated with laparoscopic cholecystectomy and bile duct injury. Most reported arterial complications are due to direct injury or diathermy shortening on surgical clips[3]. Hepatic artery pseudoaneurysm (HAP) associated with bile leak, biloma and infection are rarely reported. Here we present a rare but life threatening complication of laparoscopic cholecystectomy, their possible causes and the methods of preventing this complication.

Case Report(s)

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A 25 year old male patient underwent emergency laparoscopic cholecystectomy (LC) for acute cholecystitis of 2 days duration. Intraoperatively there was dense adhesion near the Calot’s triangle, dissection of which caused injury to the cystic artery and bleeding. Cystic artery bleeding was controlled with both diathermy and clips. Cholecystectomy was completed laparoscopically and post operative period was uneventful. But after one month, the patient came to the emergency department with acute episode of hematemesis. Endoscopy was done after stabilizing the patient which showed bleeding from the ampulla of vater. CT angiogram was done which showed a pseudoaneurysm of the right hepatic artery. Patient was stabilised and planned for radiological intervention. Hepatic artery was selectively cannulated and contrast injected [Figure-1]. There was 2 x 2 cm ² pseudoaneurysm involving the right hepatic artery close to the metals clips applied to the cystic duct during the initial laparoscopic cholecystectomy. Titanium coils were deployed at the opening of the pseudoaneurysm . Post procedure patient was asymptommatic and discharged after two days.

Discussion

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Laparoscopic cholecystectomy (LC) is the operation of choice for removal of the gallbladder. Vascular injuries are thought to occur in up to 0.8% of laparoscopic cholecystectomy cases [4]. In the presence of a bile duct injury up to 25% will have a concomitant vascular injury [5]. The commonest vascular injuries are to the right hepatic artery and cystic artery stump. These are usually not recognised at the time of surgery and present later as a pseudoaneurysm. Review of the published literature suggests that 80% of right hepatic artery pseudoaneurysms present acutely within 4 weeks with haemobilia often necessitating emergency intervention [6].
Bile duct injuries following cholecystectomy are commoner than vascular injury but vascular damage is often intimately associated with biliary injuries and can be potentially life threatening. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis. Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation. Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation.
The mechanism of injury to the hepatic artery is thought to be due to direct trauma or thermal injury [8]. As in this case, the titanium clips are often immediately adjacent to the false aneurysm and continued contact with the right hepatic artery or its segmental branches may lead to erosion. In addition the use of diathermy may lead to direct trauma or accentuated conduction through the surgical clips leading to arterial injury.
The clinical presentation of HAP is with bleeding. If discovered early the bleeding may be intermittent, but if not identified massive hemorrhage may occur with rupture and the reported mortality rate following rupture of HAP could be as high as 50%.Sandbloom's classical triad of haemobilia (gastrointestinal bleeding, epigastric pain and jaundice) is only present in 40% of patients [7]. Melaena occurs in 90% of patients, abdominal pain in 70% and jaundice in 60%. Presentations also include rupture into the peritoneal cavity and erosion into the duodenum.
Treatment of hepatic artery pseudoaneurysm is an acute emergency as the patients may exsanguinate with rupture. Early recognition is key to management. Patients with hematemesis or malena following LC should prompt an urgent endoscopy and if no cause is identified, abdominal CT and hepatic angiography should be performed. Definitive treatment with radiologic embolization is the treatment of choice of hepatic artery pseudoaneurysm [9].Pseudoaneurysm formation after laparoscopic cholecystectomy is rare. The symptoms may appear in the early postoperative period or as late as 120 days after operation. When there is compression of the bile duct or a fistula or failure of embolisation, operation is needed to repair or ligate the artery involved [10].
In this case, the pseudoaneurysm appeared very close to the metal clips that was applied during the initial laparoscopic cholecystectomy possibly because of the thermal injury to the right hepatic artery trasmitted through the metal clips in the cystic duct. These kind of injury can be avoided by taking simple precaution like careful usage of diathermy near the metal clips in the cystic duct or cystic artery and staying close to the gallbladder wall during dissection of the calot's triangle.

Conclusion

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Hepatic artery pseudoaneurysm is a rare and life-threatening complication of LC. Bile leaks and infection are predisposing factors. Hematemesis following LC should arouse the suspicion of HAP. Embolization of pseudoaneurysm is the treatment of choice and early access to this reduces the morbidity and mortality of this complication.

Source(s) of Funding

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none

Competing Interests

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none

Disclaimer

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