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Fabio Sansonna et al

erosion of a vascular char may also play a role in the coagulation in that area and ultrasonic dissection should be
pathogenesis of bleeding while fistulization into the biliary preferred. Determining if thermal damage is transmitted or
tree explains hemobilia. Hemobilia may also occur after not through the clips, is impossible, and it is unlikely either,
elective hepatobiliary surgery and emergency, open or since dissection in Calot's triangle is commonly carried out
converted cholecystectomy during which clips are never before firing clips whereas dissection in the gallbladder bed
or seldom employed; instead, severe local inflammation may requires no clip application. Other causes of vascular lesion
entail difficult dissection and thermal damage must be after LC have been described in a case occurring in a child,
the real causes of inadvertent vascular injuries in such the pseudoaneurysm of 8 mm arose in a branch of RHA
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cases. 26-30 Pseudoaneurysms of hepatic or cystic artery can that had been ligated during LC. Some authors speculate
be even secondary to acute or chronic cholecystitis, 31-33 that laparoscopic titanium clips are often found near the
and perhaps in some cases this vascular lesion was present pseudoaneurysms and may be partially responsible for arterial
even before LC. The size of pseudoaneurysms increases or biliary injuries. 12,14,15,19,22 If surgeons share this opinion,
with the time and may reach the noticeable size of 7 cm as the cystic artery and cystic duct may be interrupted by a
observed when cholecystitis is managed nonoperatively for clip and ligated by an endoloop then the clips may be gently
long time 22,31 or less frequently, when the vascular lesion removed to avoid contacts with surrounding vascular or
complicates LC and becomes symptomatic much time later. 19 biliary structures. Obviously, there is no evidence that this
In the case presented, the patient had been suffering for strategy is effective in preventing chars of arterial or biliary
months from abdominal pain, the histologic examination structures. Adopting these stategies or not is quite upto
showed a thick-walled gallbladder with acute inflammation each surgeon's choice.
and chronic cholecystitis but the pseudoaneurysm was tiny
(4 mm), hence inadvertent thermal damage must have been CONCLUSION
the only real cause of vascular complication herein described. The occurrence of severe hemobilia following LC is a life-
The cases reported in the literature often refer to surgical threatening vascular complication that can be managed
histories of difficult, time consuming LC carrying the risk successfully by TAE. Nevertheless, a means to prevent this
of inadvertent vascular injuries and pseudoaneurysm unpredictable vascular complication has not yet been
thereafter. Suggestions about prevention of such events indicated. Within the purpose of minimizing lateral thermal
cannot be found in the specific literature on this damage, the adoption of ultrasonic devices during difficult
complication, but we have enough data to argue that the dissections might be proposed to be evaluated in further
adoption of bipolar coagulation or better of ultrasonic studies.
dissection when dealing with thick-walled gallbladders
represents a good piece of advice, especially when dissection REFERENCES
digs deep into the liver bed. Under such circumstances,
possible thermal damages may be prevented by employing 1. Zilberstein B, Cecconello I, Ramos AC, Sallet JA, Pinheiro EA.
Hemobilia as a complication of laparoscopic cholecystectomy.
ultrasonic coagulation, since the potential carbonization to Surg Laparosc Endosc 1995;4:301-03.
surrounding tissues is minimal compared to laser, 1 2. Genyk YS,Keller FS, Halpern NB. Hepatic artery pseudo-
monopolar and even bipolar coagulation. 34-37 Hence, the aneurysm and hemobilia following laser laparoscopic
consequences of inadvertent injuries to biliary structures cholecystectomy. Surg Endosc 1994;8:201-04.
should be minimized by using ultrasonic instrumentation, 3. Stewart BT, Abraham RJ, Thomson KR, Collier NA. Post-
cholecystectomy hemobilia: Enjoying a renaissance in the
and hemostasis in the hepatic bed should be achieved by laparoscopic era? Aust NZJ Surg 1995;65:185-88.
absorbable hemostat products rather than by coagulation. 4. Bloch P, Modiano P, Foster D, Bouhot F, Gompel H. Recurrent
When the cystic artery arises low in Calot's triangle, below hemobilia after laparoscopic cholecystectomy. Surg Laparosc
Endosc 1994;4:375-77.
the cystic duct, the surgeon can suspect the presence of a 5. Ibrarullah MD, Singh B, Mehrotra P, Kaushik SP. Right hepatic
replaced or aberrant RHA branching off the superior artery pseudoaneurysm after laparoscopic cholecystectomy.
mesenteric artery, which can be found in 5 to 25% of Am J Gastroenterol 1997;92:528-29.
subjects. 6. Lennard TWJ, Plusa SM, Forsythe JLR, Richardson DL.
A replaced RHA is an artery supplying the right hepatic Treatment of right hepatic artery injury by percutaneous
embolization. Lancet 1994;344:1306-07.
lobe whereas an aberrant RHA is an additional branch of 7. Porte RJ, Coherkamp EG, Koumans RKJ. False aneurysm of a
38
RHA. If the suspicion of such anatomical variations is hepatic artery branch and a recurrent subfrenic abscess. Surg
present, the surgeon ought to be particularly cautious with Endosc 1996;10:161-63.

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