Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy

BACKGROUND: Although hemorrhage from the gallbladder bed during laparoscopi c cholecystectomy is one of main reasons for conversion to open cholecystec tomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS: Color Doppler ultrasound was used to examine the caus e of venous hemorrhage from the gallbladder bed during laparoscopic cholecy stectomy in 4 patients postoperatively and to examine the anatomic relation ship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS: Injury to a large branch of the middle hepatic vein adjacent to th e gallbladder bed was diagnosed in all 4 patients. One patient required con version to open cholecystectomy while the bleeding in 2 patients was immedi ately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS: Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholec ystectomy and should be identified preoperatively with ultrasound.