Recurrent bleeding right hepatic artery pseudoaneurysm after laparoscopic cholecystectomy: A case report

Abstract

Introduction: Laparoscopic cholecystectomy is the gold standard for gallbladder removal surgery, with clear advantages over open type surgery. It is rarely associated with serious complications like vasculo-biliary damage. Despite its rarity, pseudoaneurysm following laparoscopic cholecystectomy is a significant clinical phenomenon that is extremely difficult to detect. The goal is to shed light on this uncommon but potentially deadly complication.

Clinical Presentation: A 72-year-old man was hospitalized for severe protracted cholangitis and obstructive jaundice. ERCP with stent implantation was done for a large choledochal calculus. Interval laparoscopic cholecystectomy with T-tube insertion followed 2 weeks later. Recurrent haemobilia and cholangitis required three admissions in two months after cholecystectomy. On the 4th readmission, ERCP revealed intra-biliary hemorrhage, requiring source control with local hemostatic agents. Despite these measures, the hemoglobin levels dropped progressively. CT angiography of the abdomen showed an outpouching from the right hepatic artery, while an angiogram revealed a contrast leak at its posteromedial border. Pre-operative liver ultrasonography revealed a 1.8cm pseudoaneurysm sac in the porta hepatis with a ‘yin-yang’ Doppler color pattern. Trans-arterial embolization using 5-Target detachable coils were deployed in the pseudoaneurysm sac and neck. The patient was readmitted due to re-bleeding 8 days after, wherein a 2nd pseudoaneurysm, now measuring 2.0cm, was located at the posterolateral border of the 1st pseudoaneurysm. The same procedure was repeated successfully. Thereafter, the patient recovered completely.

Conclusion: Hepatic artery pseudoaneurysm is a rare but possibly fatal complication of cholecystectomy. Angiography confirms the diagnosis, and trans-arterial embolization (TAE) is successful in most cases.