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Case Reports
. 2025 Jun;21(2):1036-1039.
doi: 10.1007/s12024-024-00937-x. Epub 2025 Jan 11.

Correlation between in vivo imaging and post‑mortem autopsy findings for the medico-legal evaluation of a right hepatic artery pseudoaneurysm as a fatal complication of laparoscopic cholecystectomy

Guido Pelletti  1 , Maria Sech  2 , Nicola Montanari  2 , Emilio Quaia  3 , Domenico Garcea  4 , Susi Pelotti  2
Affiliations
Case Reports

Correlation between in vivo imaging and post‑mortem autopsy findings for the medico-legal evaluation of a right hepatic artery pseudoaneurysm as a fatal complication of laparoscopic cholecystectomy

Guido Pelletti et al. Forensic Sci Med Pathol. 2025 Jun.

Abstract

A 36-year-old woman diagnosed with complicated cholecystolithiasis underwent elective laparoscopic cholecystectomy (LC), then converted to open cholecystectomy because of a massive intraoperative bleeding. Hemostasis was performed with clipping and suturing the source of bleeding. In post-operative period, the patient suffered from persistent anemia associated with hemoperitoneum diagnosed through abdominal CT scanning, in absence of any sign of active bleeding. She died 16 days after the surgical procedure. Autopsy revealed the presence of 2 clips adjacent to the suture used for ligating the cystic artery and the presence of 3 surgical metal clips on the right hepatic artery, that should not be present in a routine cholecystectomy. The review of CT scans performed during the hospital stay revealed contrast extravasation from the right hepatic artery, near the 3 clips, allowing the post-mortem diagnosis of pseudoaneurysm (PA). The diagnosis of PA of right hepatic artery is typically made in living patients, through imaging, and autoptic identification is rarely obtained. The innovation of this report is to present an iconographic correlation between in vivo imaging and autopsy data, allowing for the tracing of the PA's origin to the wall weakening caused by the placement of 3 clips on the right hepatic artery, and having significant medico-legal implications.

Keywords: Autopsy; Cholecystectomy; Intraoperative bleeding; Post-mortem CT; Right hepatic artery pseudoaneurysm.

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Conflict of interest statement

Declarations. Ethical approval: N/A. Ethics approval and consent to participate: The current Italian legislation neither requires the family’s consent or ethical approval for a single case, as long as the data are kept strictly anonymous. Because summoning the parents was not possible as it would badly interfere with the grieving process, parents’ consent was waived, according to the Italian Authority of Privacy and Data Protection (“Garante della Privacy”: GDPR nr 679/2016; 9/2016 and recent law addition number 424/ 19th of July 2018; http://www.garanteprivacy . it). Competing interests: None.

Figures

Fig. 1
Fig. 1
Macroscopic examination of the hepatic hilum after formalin fixation: hepatic hilum structures were elevated to visualize right hepatic artery. Portal vein was pinned in blue, left hepatic artery in orange and biliary tract in green (a). On right hepatic artery were identified 5 metal clips: 2 clips were located at the origin of cystic artery (white arrow) together with a surgical wire and 3 clips were on the distal segment, according to blood flow (arrow points) (b)
Fig. 2
Fig. 2
Contrast - enhanced CT after iodinated contrast agent injection during arterial phase on arrival at the Emergency Department (a) 20-hours after admission (b) and 5 days after admission at the Emergency Department (c). The contrast leakage (arrow) at the level of hepatic artery becomes progressively larger from 2 mm (a), up to 4 mm (b) and 7 mm (c) and becomes progressively more evident
See this image and copyright information in PMC

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