REVIEW ARTICLE Combined Biliary and Right Hepatic Artery Injury during Laparoscopic Cholecystectomy Jitendra Mistry 1 & Haresh Vala 2 Received: 10 May 2020 /Accepted: 15 August 2020 # Association of Surgeons of India 2020 Abstract The most common vascular injury associated with biliary injury during laparoscopic cholecystectomy is injury to the right hepatic artery. Although the exact incidence of combined biliovascular injury is not known, but it appears frequent than expected. Ideal management of combined biliary and right hepatic artery injury is not clear, but it is advisable to repair the artery if expertise is available and situation permits. In the presence of unrepaired right hepatic artery injury, early versus delayed repair of bile duct injury is disputable, but evidences are more inclined towards delayed repair. We present two cases of combined bile duct and right hepatic artery injuries with review of literature. Keywords Biliary injury . Bile duct injury . Biliovascular injury . Vasculobiliary injury . Right hepatic artery injury . Post cholecystectomy bile duct injury Introduction Incidence [1] of bile duct injury (BDI) during laparoscopic cho- lecystectomy (LC) is 0.3–0.7%; the most common vascular in- jury along with BDI is injury to the right hepatic artery (RHA). The exact incidence of combined biliovascular injury (BVI) dur- ing LC is not known as most injuries go unnoticed. If BVI is noticed during surgery, the ideal management is debatable. We present two cases of RHA injury during LC detected and man- aged intra-operatively and discuss the review of literature. The Cases Case 1 A 30-year-old female patient was undergoing LC for symp- tomatic uncomplicated gall stone disease elsewhere in a small hospital set up. During surgery, the operating surgeon noticed bleeding and bile leak for which he opened the abdomen and achieved haemostasis by suture ligation. We received intra- operative call for the help. The assessment revealed complete transection of common hepatic duct at just below the conflu- ence (Strasberg type E2 injury), and we also found two cut and tied ends of RHA (Fig. 1a). The porta tissue, cut end of bile duct and RHA appeared healthy; there was no evidence of undue cauterisation. The patient was young and haemody- namically stable. We mobilized both ends of RHA, and they were reaching easily to each other. ###We performed end- to-end anastomosis of transected RHA using 5–0 prolene in an interrupted manner, post anastomosis the flow was established and good pulsations were palpable. Following vascular anastomosis, Roux-en-Y hepaticojejunostomy (single layer, PDS 4–0, interrupted manner, end to side, non-stented) for hepatic duct transection was performed; the incision over the bile duct was extended towards the left hepatic duct for wider anastomosis and to take advan- tage of hilar crossover blood supply. Postoperative recov- ery was uneventful, drain was removed on postoperative day 3, and she was discharged on postoperative day 7. Postoperative liver Doppler showed biphasic flow through repaired RHA, and liver function tests were within normal limits. The patient was followed up with liver function tests every 6 months, with 2 years of follow-up if she is doing well. * Jitendra Mistry jitlap@gmail.com 1 HPB & GI surgeon, GI cancers surgeon, Mission Gastrocare, an Institute of Gastroenterology, Live –Pancreas & GI cancer sciences, 02/03–Purv Prime, Near Natubhai Circle, Gotri road, Vadodara, Gujarat, India 2 Civil Hospital, Amreli, India Indian Journal of Surgery https://doi.org/10.1007/s12262-020-02569-1