'Extreme' vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders

Abstract

Objectives: Extreme vasculobiliary injuries usually involve major hepatic arteries and portal veins. They are rare, but have severe consequences, including rapid infarction of the liver. The pathogenesis of these injuries is not well understood. The purpose of this study was to elucidate the mechanism of injury through an analysis of clinical records, particularly the operative notes of the index procedure.

Methods: Biliary injury databases in two institutions were searched for data on extreme vasculobiliary injuries. Operative notes for the index procedure (cholecystectomy) were requested from the primary institutions. These notes and the treatment records of the tertiary centres to which the patients had been referred were examined. Radiographs from the primary institutions, when available, as well as those from the tertiary centres, were studied.

Results: Eight patients with extreme vasculobiliary injuries were found. Most had the following features in common. The operation had been started laparoscopically and converted to an open procedure because of severe chronic or acute inflammation. Fundus-down cholecystectomy had been attempted. Severe bleeding had been encountered as a result of injury to a major portal vein and hepatic artery. Four patients have required right hepatectomy and one had required an orthotopic liver transplant. Four of the eight patients have died and one remains under treatment.

Conclusions: Extreme vasculobiliary injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation. Contractive inflammation thickens and shortens the cystic plate, making separation of the gallbladder from the liver hazardous.

Figure 1

Patient 7. Magnetic resonance imaging shows (a) occluding thrombus in the main portal vein proximal to the site of transection (arrow) and (b) occluding thrombus in the proper hepatic artery proximal to the site of transection (arrow). The liver (L) shows minimal contrast in the veins and was found to be infarcted at surgery

Figure 2

Patient 1. Computed tomography shows (a) partial infarction of the right liver (arrow) on day 6 and (b) revascularization and atrophy of the right liver and mild hypertrophy of the left liver on day 76

Figure 3

Patient 8. Computed tomography on the day after referral shows partial infarction of the right liver. Long arrow points to infarcted liver. Short arrow points to t-tube inserted at original cholecystectomy

Figure 4

Patient 8. Percutaneous cholangiogram demonstrates an injury above the confluence of the hepatic ducts. The injury is especially high on the right; the end of one of the right ducts shows narrowing, probably indicative of ischaemia

Figure 5

The relationship between the cystic plate and the right portal pedicle (a) under normal circumstances and (b) in the presence of severe contractive inflammation. The cystic plate attaches to the anterior surface of the right portal pedicle. Dissection downward in the plane deep to the plate (arrow) will lead to the pedicle, with injury to the vessels and bile duct. When inflammation is mild, as in (a), entry into the plane is usually readily detected by visualization of liver tissue. When there is severe contractive inflammation the cystic plate is thickened, as in (b), and determining the position of the dissection in relation to the plate is difficult. In addition, the plate is foreshortened so that the distance from the top of the plate to the pedicle is very short. Both of these factors greatly increase the likelihood of injury to the pedicle