Challenges of Duplicated Portal Vein in Elective Laparoscopic Cholecystectomy: A Case Report

Abstract

BACKGROUND Anatomical variations of the portal system are not uncommon. Misidentifying structures of the hepatoduodenal ligament can precipitate tremendous adverse events during elective cholecystectomy. Preoperative radiological imaging is usually limited to ultrasound examination, which alone does not provide sufficient anatomical knowledge of the liver hilum. CASE REPORT This report presents a case of a 61-year-old woman after cholecystectomy, with iatrogenic bile duct injury and packing, due to abdominal hemorrhage derived from portal vein rupture. The patient required immediate relaparotomy and abdominal depacking, due to excessive compression of the hepatoduodenal ligament and insufficient portal blood flow. Surgery was limited to depacking and repair of the lacerated portal vein. The abdominal drainage was performed to stabilize the patient's general condition. Intraoperative ultrasound identified poor portal flow (V<10 cm/s) and intrahepatic portal thrombosis. Further treatment continued in the Intensive Care Unit, where she received anticoagulation treatment and was qualified for liver transplantation. The cavernous transformation of the portal vein was identified, along with several other anatomical variations, including a low-positioned splenomesenteric venous confluence, right-shifted pancreas, and intestinal malrotation, among other minor vascular abnormalities. During the next days, her general condition improved; following extubation, she was transferred to the Surgery Unit. A biliary fistula was managed by percutaneous transhepatic drainage and biliary stenting. Liver transplantation was not necessary. CONCLUSIONS This case highlights the extremes of vascular and biliary injury following elective cholecystectomy, partially due to lack of preoperative radiological examination, and portrays the elevated risk of mortality and burden of further medical treatment.

Figure 1.

Hepatic biloma (white arrow) on the computed tomography.

Figure 2.

Portal vein narrowing shown on the computed tomography.

Figure 3.

Self-expanding metal stent placement location following endoscopic retrograde cholangiopancreatography, indicated by the white arrow.

Figure 4.

Reconstruction of the portal venous system, demonstrating atypical right portal vein (RPV) with retro-pancreatic and pre-duodenal course and atypical left portal vein (LPV), splenic vein (SV), and superior mesenteric vein (SMV).

Video 1.

Anatomical anomalies on computed tomography.

Video 2.

Portal venous system reconstruction.