Lesson learned from hemorrhage and conversion during treatment of acute cholecystitis

The objective of this clinical case is to illustrate the potential anatomical difficulties that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis.

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Lesson learned from hemorrhage and conversion during treatment of acute cholecystitis

Authors

V Podelski, B Dallemagne, D Mutter, J Marescaux

Abstract

The objective of this clinical case is to illustrate the potential anatomical difficulties that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis.

Classification

tips and tricks

Keywords

hemorrhage, conversion, treatment, acute cholecystitis

Media type

Surgical video

Duration

05'00''

Publication

2011-07

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E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3219.htm

Lesson learned from hemorrhage and conversion during treatment of acute cholecystitis

1. Introduction 00'20''

The objective of this clinical case is to illustrate the potential anatomical difficulties that may be encountered during the dissection of Calot’s triangle in the management of acute cholecystitis. Typically, the gallbladder would be retracted cranially by the surgeon in order to dissect Calot’s triangle.

2. Calot’s triangle dissection 00'39''

The position of the common bile duct and cystic duct respectively are simulated. It becomes clear that the dissection as performed by the surgeon is situated posterior to the hepatic ligament. This way too posterior dissection leads the surgeon to come in contact with a dividing branch of the right hepatic artery. Attempts are made to identify this branch in transparency as it offers a pearly sheen.

3. Bleeding 01'04''

Since this dissection error has not been identified just yet, the dissection will be carried on using the hook. However, it induces active bleeding. Faced with such a complication, the first decision to make is to compress the bleeding lesion in order to identify and manage it.

4. Gauze introduction 01'29''

The first operative step is to introduce a gauze pad placed in the hemorrhagic region. It would be ill-advised to use cautery or clip placement in a blind fashion. An inappropriate vascular control could have harmful consequences for the patient. The application of the gauze pad and gradual compression help to identify the seat of the hemorrhage. However, it is uneasy to identify the artery with certainty since it is bleeding as can be seen here. Several attempts are made. Optimal exposure cannot be obtained even though the surgeon uses a forceps to retract the gallbladder bed as well as two operating instruments and a camera. Compression by means of a gauze pad or an aspirator is used in order to identify the bleeding area. If the maneuvers turn to be adequate at that point, the importance of bleeding forces the surgeon to find other ways to identify the injured area. An effective compression is achieved by means of a rolled up gauze pad.

5. Additional port insertion 02'49''

An additional port is then placed. Indeed, a proper identification of the area cannot be achieved with 4 ports only. This fifth port will allow to progressively free the gallbladder, hoping to achieve a retrograde approach to the hepatic pedicle.

6. Conversion 03'04''

Nonetheless, each instrument mobilization brings about further bleeding. The importance and the recurrence of bleeding makes control of the artery uncertain and postoperative outcome unsafe for the patient, forcing the surgeon to convert.

7. Hemorrage control 03'18''

An accessory posterior branch of the right hepatic artery will eventually be ligated using 4/0 Prolene material and the procedure is completed uneventfully.