Introduction:

Early laparoscopic cholecystectomy is the golden standard treatment for acute cholecystitis [1]. The exact learning curve definition for laparoscopic cholecystectomy was not clearly defined because of the high variability of surgical scenario, but 25 procedures might be sufficient to acquire technical competency in laparoscopic cholecystectomy [2-3].

Persistent intraoperative bleeding can be a challenging complication, particularly when unexpected sources are involved.

Case Presentation:

We present a case of a 60-year-old male patient admitted with severe right upper quadrant pain, fever, and leukocytosis. No comorbidities. No previous abdominal surgeries. Acute cholecystitis was confirmed through clinical evaluation and imaging studies. An urgent laparoscopic cholecystectomy was planned at night. An empirical antibiotic therapy was administered early at admission.

Intraoperatively, extensive adhesions due to severe inflammation complicated the dissection process and obtaining the Critical View of Safety (CVS). Despite careful handling, the procedure was abruptly complicated by persistent and severe arterial bleeding. Maintaining composure, checking the normal anatomy to recognise the source of the bleeding and the biliary tree, in order to avoid injuries to the biliary duct or to the right hepatic artery, the surgical team employed laparoscopic techniques to achieve hemostasis without negative outcomes or conversion to laparotomy.These included gauze compression, suction and irrigation to clear the field, followed by careful clipping and ligation of the aberrant cystic artery. No postoperative complications occurred. The abdominal drain was removed at PO day 3 and the patient was discharged to home. At 1-month follow-up, the patient was fully recovered, without complications.

Discussion:

Iatrogenic bile duct injury still occurs in 0.2% to 0.8% of cases following cholecystectomy. In addition vascular damage can occur in approximately 12% to 61% of iatrogenic bile duct injury cases [4-6]. Uncontrolled bleeding from the cystic artery and its branches is a serious problem that may increase the risk of intraoperative injury to vital vascular and biliary structures. Anatomic variations of the cystic artery are frequent and can differ in origin, position and number[6-8]. The cystic artery variations were classified into three groups according to the position: (group 1) Calot’s triangle, (group 2) outside Calot’s triangle, and (group 3) compound type[8-11]. This case illustrates the critical importance of being prepared for unexpected anatomical cystic artery variations during laparoscopic cholecystectomy, especially in the setting of severe inflammation. When the anatomy of the Calot’triangle is not clear, and in case of persistent arterial bleeding of unknown origin, the use of ICG cholangiography is useful to avoid injuries to the biliary tract and to the right hepatic artery [12-14]. Prompt conversion to the open approach is always a safe option to consider.

Conclusion:

Persistent intraoperative bleeding during laparoscopic cholecystectomy for acute cholecystitis is a serious complication. Intraoperative vigilance and anatomy knowledge are essential to manage difficult laparoscopic cholecystectomy. The use of ICG fluorescence cholangiography/angiography is a valid tool to avoid injuries to the biliary duct or to the right hepatic artery. Prompt conversion to the open approach is always a safe option to consider.

References

1. Pisano, M., Allievi, N., Gurusamy, K. et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 15, 61 (2020). https://doi.org/10.1186/s13017-020-00336-x
2. Lombardi, P.M., Mazzola, M., Veronesi, V. et al. Learning curve of laparoscopic cholecystectomy: a risk-adjusted cumulative summation (RA-CUSUM) analysis of six general surgery residents. Surg Endosc 37, 8133–8143 (2023). https://doi.org/10.1007/s00464-023-10345-x
3. Reitano E, de’Angelis N, Schembari E, Carrà MC, Francone E, Gentilli S, La Greca G. Learning curve for laparoscopic cholecystectomy has not been defined: A systematic review. ANZ J Surg. 2021 Sep;91(9):E554-E560. doi: 10.1111/ans.17021. Epub 2021 Jun 28. PMID: 34180567; PMCID: PMC8518700.
4. Thomas B. Hugh, Michael D. Kelly, Bei Li,Laparoscopic anatomy of the cystic artery. The American Journal of Surgery,Volume 163, Issue 6,1992,Pages 593-595,ISSN 0002-9610,https://doi.org/10.1016/0002-9610(92)90564-8.
5. Fateh, O., Wasi, M.S.I. & Bukhari, S.A. Anaotmical variability in the position of cystic artery during laparoscopic visualization. BMC Surg 21, 263 (2021). https://doi.org/10.1186/s12893-021-01270-8
6. Dandekar, Usha, Dandekar, Kundankumar, Cystic Artery: Morphological Study and Surgical Significance, Anatomy Research International, 2016, 7201858, 6 pages, 2016. https://doi.org/10.1155/2016/7201858
7. Ding YM, Wang B, Wang WX, Wang P, Yan JS.New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy. World J Gastroenterol 2007; 13(42): 5629-5634 [PMID: 17948938 DOI: 10.3748/wjg.v13.i42.5629]
8. Pesce A, Fabbri N, Feo CV. Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication. World J Gastrointest Surg. 2023 Mar 27;15(3):338-345. doi: 10.4240/wjgs.v15.i3.338. PMID: 37032796; PMCID: PMC10080601.
9. Lopez-Lopez V, Kuemmerli C, Cutillas J, Maupoey J, López-Andujar R, Ramos E, Mils K, Valdivieso A, Valero AP, Martinez PA, Paterna S, Serrablo A, Reese T, Oldhafer K, Brusadin R, Conesa AL, Valladares LD, Loinaz C, Garcés-Albir M, Sabater L, Mocchegiani F, Vivarelli M, Pérez SA, Flores B, Lucena JL, Sánchez-Cabús S, Calero A, Minguillon A, Ramia JM, Alcazar C, Aguilo J, Ruiperez-Valiente JA, Grochola LF, Clavien PA, Petrowsky H, Robles-Campos R. Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama. Surgery. 2022 Oct;172(4):1067-1075. doi: 10.1016/j.surg.2022.06.020. Epub 2022 Aug 12. PMID: 35965144.
10. Andall RG, Matusz P, du Plessis M, Ward R, Tubbs RS, Loukas M. The clinical anatomy of cystic artery variations: a review of over 9800 cases. Surg Radiol Anat. 2016 Jul;38(5):529-39. doi: 10.1007/s00276-015-1600-y. Epub 2015 Dec 23. PMID: 26698600.
11. De Simone, B., Abu-Zidan, F.M., Saeidi, S. et al. Knowledge, attitudes and practices of using Indocyanine Green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)—WSES project. Updates Surg (2024). https://doi.org/10.1007/s13304-024-01853-z%5D.
12. Di Maggio F, Hossain N, De Zanna A, Husain D, Bonomo L. Near-Infrared Fluorescence Cholangiography can be a Useful Adjunct during Emergency Cholecystectomies. Surg Innov. 2022 Aug;29(4):526-531. doi: 10.1177/1553350620958562. Epub 2020 Sep 16. PMID: 32936054.
13. Stolz MP, Foxhall EN, Gibson BH, Gill S, McNamee MM. Improving the Safety of Laparoscopic Cholecystectomy with Indocyanine Green Dye Using Critical View of Safety Plus. Am Surg. 2023 Jul;89(7):3136-3139. doi: 10.1177/00031348231161659. Epub 2023 Mar 1. PMID: 36857190.;
14. D’Acapito F, Cucchetti A, Solaini L, Serenari M, Framarini M, Ercolani G. Fluorescence Cholangiography Using Indocyanine Green Improves the Identification of Biliary Structures During Laparoscopic Cholecystectomy. World J Surg. 2023 Mar;47(3):666-673. doi: 10.1007/s00268-022-06854-w. Epub 2022 Dec 2. PMID: 36459198.