A 74 years-old woman with symptomatic cholelithiasis was admitted to the hospital and underwent radiological diagnostics (Tomography computed and ultrasound examination) with findings of gallstones. The patient was submitted laparoscopic cholecystectomy. Intraoperatively, the surgeon described omental adhesions, severe inflammation, a cystic artery with anatomical variant (multiple collateral branches) and a short cystic duct. The surgical procedure was complicated by profuse bleeding, therefore the surgeon decided for hemostatic suture to stop the bleeding. Postoperatively, the woman showed immediately right upper quadrant abdominal pain and significant deterioration of the liver function tests. The CT evidenced right hepatic ischemia. The patient was transferred to a third level hospital, and underwent laparotomic surgery with right hemihepatectomy and a Roux-en-Y hepaticojejunostomy 8 days after from first laparoscopic surgery. The operative note described “completely dissected distal common bile duct, unrecognizable proximal common bile duct and the biliary confluence, sutured to the portal branch for the segments 8 and 5, clips on the right hepatic artery.” Afterwards onset of fever with progressive deterioration of her general condition and she died two months after the first operation due to sepsis. The autopsy showed ascites, adhesions between the diaphragm, liver and intestinal structures, outcomes of right hepatectomy with suture between the biliary ducts and the jejunal loops; integrity of the surgical anastomosis; lesion of the right hepatic artery. The histological examination showed: ischemic and gangrenous hepatic necrosis indicative of a septic complication, diffuse intrahepatic cholestasis and acute respiratory distress syndrome. The case is very interesting for various medico-legal aspects: informed consent about conversion to laparotomy, the experience of operator in different surgical techniques, the pre-operatively possibility of anatomical variations exploration, the evidence of the causal chain. Review of the literature revealed that bile duct injury is a frequent operative complication of laparoscopic cholecystectomy, but also indicated the rarity of concomitant arterial and venous lesions. The lesion of the portal vein system appears to be associated with rapid hepatic necrosis and with an increase of the morbidity and the mortality. However in this case exitus occurred approximately two months after laparoscopic surgery secondary to complications. The evaluation of medical malpractice aspects is complex and requires adequate attention to the presence of an anatomic variant, and eventually to the prompt conversion from laparoscopic cholecystectomy to a laparotomic approach and to anatomo-pathological finds.
MEDICO-LEGAL ASPECTS IN A CASE OF LAPAROSCOPIC CHOLECYSTECTOMY WITH CONCOMITANT BILIARY, VENOUS AND ARTERIAL IATROGENIC LESIONS
CIRIELLI, Vito;MONTAGNA, Oriella;TURRINA, Stefania;DE LEO, Domenico
2012-01-01
Abstract
A 74 years-old woman with symptomatic cholelithiasis was admitted to the hospital and underwent radiological diagnostics (Tomography computed and ultrasound examination) with findings of gallstones. The patient was submitted laparoscopic cholecystectomy. Intraoperatively, the surgeon described omental adhesions, severe inflammation, a cystic artery with anatomical variant (multiple collateral branches) and a short cystic duct. The surgical procedure was complicated by profuse bleeding, therefore the surgeon decided for hemostatic suture to stop the bleeding. Postoperatively, the woman showed immediately right upper quadrant abdominal pain and significant deterioration of the liver function tests. The CT evidenced right hepatic ischemia. The patient was transferred to a third level hospital, and underwent laparotomic surgery with right hemihepatectomy and a Roux-en-Y hepaticojejunostomy 8 days after from first laparoscopic surgery. The operative note described “completely dissected distal common bile duct, unrecognizable proximal common bile duct and the biliary confluence, sutured to the portal branch for the segments 8 and 5, clips on the right hepatic artery.” Afterwards onset of fever with progressive deterioration of her general condition and she died two months after the first operation due to sepsis. The autopsy showed ascites, adhesions between the diaphragm, liver and intestinal structures, outcomes of right hepatectomy with suture between the biliary ducts and the jejunal loops; integrity of the surgical anastomosis; lesion of the right hepatic artery. The histological examination showed: ischemic and gangrenous hepatic necrosis indicative of a septic complication, diffuse intrahepatic cholestasis and acute respiratory distress syndrome. The case is very interesting for various medico-legal aspects: informed consent about conversion to laparotomy, the experience of operator in different surgical techniques, the pre-operatively possibility of anatomical variations exploration, the evidence of the causal chain. Review of the literature revealed that bile duct injury is a frequent operative complication of laparoscopic cholecystectomy, but also indicated the rarity of concomitant arterial and venous lesions. The lesion of the portal vein system appears to be associated with rapid hepatic necrosis and with an increase of the morbidity and the mortality. However in this case exitus occurred approximately two months after laparoscopic surgery secondary to complications. The evaluation of medical malpractice aspects is complex and requires adequate attention to the presence of an anatomic variant, and eventually to the prompt conversion from laparoscopic cholecystectomy to a laparotomic approach and to anatomo-pathological finds.
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