Laparoscopic management of post-cholecystectomy sectoral artery pseudoaneurysm
A 29-year-old male underwent laparoscopic cholecystectomy. At operation, Callot's anatomy was normal. Gall bladder was mildly inflamed containing multiple stones. Cystic artery was small and divided with harmonic scalpel in coagulating mode after double sealing. Cystic duct clipped with locking clip and divided.\nAfter 2 weeks, the patient was readmitted to the hospital with complaints of fatigue. He appeared pale, afebrile, with pulse rate of 100 and blood pressure 110/60 and mild guarding over the right upper abdomen. Plain film of the abdomen showed no pathology. Blood investigation showed haemoglobin 8. 6 g/dl (pre operative was 15.6), bilirubin 2.7 mg/dl with indirect bilirubin 1.6, signifying haemolysis, and slight increase in liver enzymes (aspartate aminotransferase 138UI/L; alanine aminotransferase 106 UI/L). Abdominal ultrasound followed by computed tomographic (CT) angiography with vascular reconstruction revealed intraperitoneal blood, mainly in Gallbladder fossa, with active bleed (contrast blush) from right posterior sectoral artery pseudo aneurysm [].\nThe angiographic embolisation was discussed. As the bleeder originated from right hepatic artery very near the bifurcation of hepatic artery proper, there was a possibility that not only right hepatic artery, but hepatic artery proper also may need to be embolized to control the bleed risking massive liver necrosis. So, operative exploration was decided. After stabilisation, we proceeded with laparoscopy, keeping an open instrument trolley ready for laparotomy.\nAt laparoscopy, intra-abdominal blood clots were suctioned out and gall bladder fossa adhesions were dissected with suction tip. The pulsating pseudoaneurysm with clot was identified in the right hepatic artery/cystic artery area. While trying to dissect the right hepatic artery, the pseudoaneurysm started to bleed. Combination of pressure, suction, and temporary control with clips failed. While contemplating conversion, we put in an extra port and applied laparoscopic Pringle (vascular) clamp as that would have been the first step after conversion. The bleeding immediately reduced to a trickle. It was now possible to clearly identify the right hepatic artery and the sectoral artery stump and intracorporeally suture ligate the offending artery stump at the base taking some peri-arterial tissue to prevent slipping of the suture []. The controlled environment helped taking precise bites. As per CT, the bleeding point was away from right hepatic duct so risk of biliary injury was minimal. The patient made an uneventful recovery.