M

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MM

• Uliyargoli.A
• 9/18/07

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• s/p Lap cholecystectomy Post-op Intra-abdominal
  hemorrhage
• S/P Sleeve gastrectomy PCA-Narcotic overdose
• S/P Exp. Laparoscopy PCA-Narcotic overdose
  

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• 44 F, HIV, Stroke sec to cocaine abuse,
• Severe RUQ abd, Acute onset-1 day
• Nausea and vomiting, non bilious, no hematemesis
• Low grade fever, no chills, no sweats
• Reg BM, no malena

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• PMH- HIV-3 yrs, Stroke-Rt. thalamic
• PSH- Nil
• Meds- Methadone in the past
• All- NKDA
• Per- Cocaine, IVDA-quit I yr ago, smoker-1ppd for
  7 years, No ETOH

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• O/E- 36.6, 205/100, 60, 20, 100/RA
• RUQ tenderness, No gaurding, No rigidity
• Prov. Diag- Ac. Cholecystitis
• Labs- WBC 8.5, H/H-11/34, Plt-296, Coags-N,
  Urine- cocaine ,
• U/S abdomen

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U/S- Distended GB with pericholecystic fluid,
Stone at neck and cystic duct junction, CBD 6mm
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• HTN- controlled, Unasyn coverage
• Lap cholecystectomy- Inflammed gall bladder,
  needle aspirated,
• Difficult dissection off GB bed
• Bleeding off the liver on segment 4
• Complete homeostasis obtained

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• Post-op D1
• Initial Bp -170/90 with a gradual trend down to
  140/75 over the next 24 hrs. Treated with
  labetolol and clonidine.
• Fevers on POD 1
• Tachycardia -100-120
• Urine output -55ml/hr
• Abd- mild gen distension
• Post-op Hct- 11.8/34

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• POD2- Bp- 120/70 (one recording of 90/60
  overnight), hr-80,
• Approx. 36 hrs post-op -return of am labs
• H/H- 6.6 /19
• O/E- AAO, Hr-80, Bp-120/70, mild abd distension,
  decrease in UO
• Rpt Hct orderd- 6.6/18
• Pt was emergently taken to the OR

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• Expl. Laparoscopy- Large amt of blood clot in the
  abd- approx 800ml lavaged out
• Bleeding from lateral GB fossa edge-controlled
• Some bleeding from porta hepatis area- controlled
• Continued pooling of blood from behind porta
  hepatis and bile staining of the medial aspect of
  GB fossa
• Cystic duct endo-looped
• Persistent bleeding from Fat laden porta-hepatis
• Porta-hepatis dissected- Large perforating vein
  coming posterior from the porta hepatis ,
  developed brisk bleeding and hence converted to
  open

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• Pringle maneuver to control bleeding and
  resuscitation
• Kocher maneuver- to expose posterior aspect of
  portahepatis better and isolation of bleeding
  vessel and suture ligation
• Pt transferred to ICU in stable condition
• EBL-4L, 14BT, 4 FFP, 4units Plts,

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• Post-op HD Stable
• H/H 12/33, Good UO, BUN/Cr 15/0.8, INR -1. PT-11,
  PTT-27
• ABG- 7.38/38/200/23/-3
• Pt extubated approx 18-20 hrs later
• T.Bil- 1.1 to 1.8, AP-77 to 170, AST/ALT 200/130
  to 53/56

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• Pt with persistent fever on POD 2 from her 2nd
  surgery
• Bile c/s Strep viridans and candida albicans
• On Vanc, zosyn and Diflucan
• CT scan on POD3- B/L lower lobe consolidation,
  soft tissue density in the bed of gallbladder,
  moderate acites

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• POD 4- Hida scan
• Highly suspicious for bile leak

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Complication

• Post op secondary hemorrhage
• Post op bile leak

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J of Am coll. Surg 1995, Strasberg, Hertl, Soper-
8856 cases

• Major bleeding - 1.38
• Wound infection - 0.6
• Bile leak - 0.4
• Bil. injury -0.2
• Bowel injury - 0.16
• Total -2.58

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Hepatic vein injury during lap chole-the
unappreciated proximity of mid hepatic vein to
the GB bed. J of GI surgery 2006 sept-Oct 10(8) ,
Bill, MacLean, Kirkpatrick, et al

• 0.1 to 0.9 incidence of uncontrollable
  hemorrhage
• 88 of hemorrhage occurs from GB bed
• Large branches(gt2.1mm) of mid hepatic vein are
  directly adjacent to GB bed in 10 of pts
• Additional 10 have branches within 1mm of the GB
  bed
• Chr, scarred and contracted GB increase risk of
  bleeding requiring conversion