Abstract

During laparoscopic cholecystectomy (LC) for acute cholecystitis, identification of vital structures can be particularly challenging due to settled inflammatory situations. Moreover, the prevalence of vascular variations and cystic artery aberrations heightens the risk of vascular injury, potentially leading to intraoperative haemorrhage. Such complications can be overwhelming to manage and pose a significant threat to patient safety, due to compromised surgical view and fragile tissues.

The purpose of the current case report is to demonstrate that laparoscopic cholecystectomy can still be successfully completed in cases of challenging acute cholecystitis, even with the presence of unexpected bleeding, ensuring patient safety.

Intraoperative vigilance and anatomy knowledge are essential to manage difficult laparoscopic cholecystectomy. The use of Indocyanine Green (ICG) fluorescence cholangiography/angiography is a valid and effective tool to avoid injuries to the biliary tract or to the right hepatic artery when equipment and skills are available. Prompt conversion to the open approach is always a safe option to consider, as it ensures patient safety.

Introduction

Bleeding complications from vascular injuries are significant contributors to morbidity and mortality, particularly during laparoscopic procedures, where managing major haemorrhages can be technically demanding for young surgeons in urgent settings. (1)

Laparoscopic cholecystectomy (LC) is the golden standard treatment of acute cholecystitis. (2-3) The majority of procedures can be relatively straightforward and feasible when performed by experienced surgeons who follow the established protocols. (1,4) Nevertheless, specific surgical findings may complicate the procedure, heightening the risk of adverse outcomes.

Two decades ago, performing an LC for acute cholecystitis was considered a relative contraindication mainly due to the progressive rates of the common bile duct and vascular-biliary injuries at a time when laparoscopy was still evolving as a technique. (5,6)

Nowadays LC is the golden standard treatment for acute cholecystitis in all fitted for surgery patients (3). Currently, this procedure is correlated to uncontrolled intraoperative bleeding from vascular injuries in approximately 0.9% to 1.9% of cases, with the gallbladder bed identified as the primary source of bleeding, predominantly involving the middle hepatic vein and its major branches. (7)

While much emphasis has been placed on biliary injuries and the strategies for preventing and managing bile duct injuries, vascular injuries have received comparatively less attention. (8,9)

It is crucial for surgeons to accurately identify vascular anomalies/variations to control injuries and select the most appropriate therapeutic intervention for prompt repair, taking into account their surgical expertise and the available resources at their medical facility.

This case report aims to demonstrate that laparoscopic cholecystectomy can effectively address challenging cases of acute cholecystitis. Intraoperative bleeding can be associated with negative outcomes. Anatomy knowledge and the prompt recognition of variations are essential to increase patients’ safety and avoid vascular and biliary injuries. This case report complies with the SCARE criteria. (10)

Case Presentation

A 60-year-old male with a history of hypertension presented to the emergency room with a 72-hour history of fever, nausea, vomiting, and right upper quadrant (RUQ) abdominal pain. Physical examination revealed a positive Murphy’s sign. Laboratory tests showed leukocytosis (14,000 cells/µL) and an elevated C-reactive protein (CRP) level (150 UI), indicative of inflammation, while liver function tests were normal. A contrast-enhanced abdominal CT scan confirmed acute cholecystitis.

Following 24 hours of fluid resuscitation and empirical antibiotic treatment with ceftriaxone (2 grams IV every 12 hours), the patient underwent LC. During surgery, extensive adhesions and fibrinous deposits were noted, complicating visualization of the surgical field (figure 1). After careful dissection, the cystic duct was clipped successfully. However, unexpected bleeding occurred from an aberrant cystic artery, which was short, retracted, and originated from the right hepatic artery (Figures 2 and 3).

Despite efforts to control the bleeding using laparoscopic pads and attempting to clip the artery, these measures were unsuccessful. The surgical team decided to suture the aberrant artery using Vicryl 000 and PDS 000 with interrupted stitches, effectively controlling the haemorrhage without damaging the hepatic hilum or adjacent structures. The patency of the right hepatic artery was confirmed by observing normal liver colouration and the absence of ischemic demarcation.

Due to the lack of availability of Indocyanine Green (ICG) fluorescence imaging, this technique could not be utilized. A suction drain was placed in a subhepatic position before completing the procedure. The patient’s postoperative course was uneventful, with no signs of bleeding or bile leakage. The drain was removed on the third postoperative day, and at a one-month follow-up, the patient remained asymptomatic with normal liver function tests.

Discussion

Bleeding is a major concern during LC for acute cholecystitis, categorized as a ‘non-biliary’ injury. If not promptly recognized and managed, it can lead to severe morbidity and even mortality. The cystic artery, usually originating from the right hepatic artery, frequently varies in its course and branching, increasing the risk of injury during surgery.  Despite its importance, the bleeding complications have not been comprehensively studied and reported. (9)

A crucial step in achieving the critical view of safety (CVS) during LC is the visualization and control of the cystic artery. The cystic artery is located within the hepatobiliary triangle, which is defined by the inferior surface of the liver, the cystic duct, and the common hepatic duct. However, there are significant anatomical variations; although a single cystic artery is usually present, multiple cystic arteries may also be encountered (11,12).

The incidence of uncontrollable bleeding in LC can range up to 2% (with rates varying from 0.03% to 10%), although the actual figure may be significantly higher. (11) Vascular injuries, such as bleeding from the cystic artery, may necessitate conversion to open surgery in up to 1.9% of cases, with a mortality rate of approximately 0.02%.(8,9,13,14)

A review published in 2016 examined over 9,800 cases through cadaveric dissections, Computed Tomography (CT) Angiography, and intraoperative studies, to investigate the type-end incidence of cystic artery variations. It showed that only 79.02% of cystic arteries originate from the right hepatic artery, and 81.5% pass-through Calot’s triangle. Additionally, 8.9% of specimens contained multiple cystic arteries, with 4.9% displaying a cystic artery that ran inferior to the cystic duct or Calot’s triangle. Other origins for the cystic artery included the left hepatic artery, aberrant right hepatic artery, gastroduodenal artery, proper hepatic artery, celiac trunk, proper hepatic bifurcation, superior pancreaticoduodenal artery, and superior mesenteric artery (15).

Table 1 summarises the different available anatomical classifications of cystic artery variations.

ICG imaging can significantly enhance visualization of the biliary and vascular structures, helping to prevent injuries, especially in inflamed cases (16). However, the absence of this technology should prompt a low threshold for conversion to open surgery to ensure patient safety.

In case of persistent intraoperative bleeding, the decision-making and management primarily depend on the patient’s overall general conditions and the anesthesiologist’s assessment of risk. Prompt conversion to laparotomy is always an option to consider in case of hemodynamic instability of the patient to ensure his/her safety.

To avoid intraoperative bleeding of the cystic artery, cholecystectomy with proximal ligation or clipping of the cystic artery is considered the gold standard surgical technique. In the presence of persistent bleeding with difficult scenarios, including multiple injuries to the artery and the patient is in poor condition, alternative strategies may be required (17,18).

Transarterial embolization (TAE) is an option when available, to stop the bleeding in up to 90% of cases. (18–20)

Additionally, percutaneous selective cystic artery embolization (CAE) has emerged as an effective tool in life-threatening situations for patients with complications from either cystic artery bleeding or cholecystitis and bleeding. CAE offers several advantages over surgical exploration for haemorrhage during cholecystectomy including lower mortality and morbidity rates, better identification of the source of bleeding, and higher rates of haemorrhage control.(21) Embolization techniques generally utilize coils, glue, or Gelfoam for the procedure. Although CAE is generally considered safe, it does carry certain risks. Non-target embolization of the hepatic parenchyma can happen, potentially leading to rare complications associated with hepatic artery embolization, such as ischemic hepatitis and abscess development. (22)

In either scenario, careful post-procedural monitoring is essential to early detect further complications.(23)

Conclusions

The detection and careful ligation of the cystic artery is an essential step of a safe laparoscopic cholecystectomy, according to the CVS technique. It is important to know that the cystic artery is notable for its frequent anatomical variations regarding its origin, branching patterns, and termination. Intraoperative vigilance and anatomy knowledge are essential to manage difficult laparoscopic cholecystectomy, complicated by unexpected bleeding, and to ensure patient safety. The use of ICG fluorescence imaging for intraoperative navigation is a valid and effective tool to avoid injuries to the biliary ducts and to the hepatic vessels, when equipment and skills are available. Prompt conversion to the open approach is always a safe option to consider in case of uncontrolled and persistent bleeding.

Table 1: Classification of Cystic Artery Variations