Case Report Emergency Liver Resection for Combined Biliary and Vascular Injury Following Laparoscopic Cholecystectomy: Case Report and Review of the Literature Evangelos Felekouras, MD, Thomas Megas, MD, Othon P. Michail, MD, Ioannis Papaconstantinou, MD, Nikolaos Nikiteas, MD, Dimitrios Dimitroulis, MD, John Griniatsos, MD, Anastasios Tsechpenakis, MD, and Gregorios Kouraklis, MD Abstract: A 75-year-old woman suffering from symptomatic cho- lelithiasis was admitted to our hospital for elective laparoscopic cholecystectomy (LC). Intraoperatively, because of severe inflam- mation and dense adhesions in the region of the Calot triangle and bleeding arising from the porta hepatis which obscured the operating field, the method was converted to a conventional open approach. Copious hemostasis was achieved using sutures, clips and diathermy, and no bile duct or vascular injuries were recognized intraopera- tively. Because of severe right upper quadrant abdominal pain and significant deterioration of the liver function tests (LFTs) on the first postoperative day, the patient underwent a Doppler ultrasound scan which showed absence of blood flow at the level of porta hepatis. Urgent relaparotomy revealed an ischemic liver on the right, a transected common bile duct at the level of its confluence, a divided and ligated right hepatic artery and thrombosed portal vein down to its confluence. Thrombectomy and reconstruction of the portal vein were performed to salvage the left hemiliver, and after restoration of blood flow to the left hemiliver, a right hemihepatectomy and a Roux-en-Y hepaticojejunostomy on the left were performed. Liver resection serves an important role in the case of parenchymal necrosis due to combined biliary, hepatic artery and portal vein injury following laparoscopic cholecystectomy and moreover, the operation can be safely performed in the acute setting. Key Words: laparoscopic cholecystectomy, bile duct injury, hepatic artery injury, portal vein injury, hepatectomy, liver resection L aparoscopic cholecystectomy (LC) constitutes the opera- tion of choice for symptomatic gallstone disease. 1 Mean- while, a 0.62% incidence of postcholecystectomy biliary injury has been reported. 2 Concomitant vascular injuries complicate the course of these patients with an incidence of 47%. 3 The combination of biliary and vascular injury following LC contributes significantly to the postoperative morbidity and mortality, particularly in cases of delayed diagnosis. 4–7 The degree of the hepatic damage, the need for liver resec- tion, or even liver transplantation are also contributing factors of the morbidity and mortality. 4,5,8 Case Report A 75-year-old female patient suffering from symptom- atic cholelithiasis underwent elective laparoscopic chole- cystectomy (LC). Because of severe inflammation and dense adhesions at the region of Calot triangle and bleeding aris- ing from the porta hepatis which obscured the operating field, LC was converted to an open procedure through a standard right subcostal incision. Copious hemostasis was achieved us- ing sutures, clips and diathermy, and no bile duct injury was recognized intraoperatively. On the first postoperative day, the patient complained of constant and severe right upper quadrant abdominal pain, while liver function (continued next page) From the Department of Surgery, University of Athens, Medical School, LAIKO Hospital, Athens, Greece. Reprint requests to Dr. Othon P. Michail, 30 Roumbessi str, Halandri, Ath- ens, Greece. Email: omichail@yahoo.com Accepted July 13, 2006. Copyright © 2007 by The Southern Medical Association 0038-4348/0-2000/10000-0317 Key Points • Combined biliary, hepatic artery and portal vein in- jury at the level of porta hepatis can occur following laparoscopic cholecystectomy. • Liver resection in the acute setting (20 h after lapa- roscopic cholecystectomy) can be safely performed. Southern Medical Journal • Volume 100, Number 3, March 2007 317