A rare complication of laparoscopic surgery.

Gallstone disease is one of the most common problems affecting the digestive tract. Symptomatic patients are advised to undergo laparoscopic cholecystectomy (LC), which is considered the gold standard of care in these patients. LC has clear advantages over traditional surgery such as a shorter hospital stay, an earlier return to work and better patient satisfaction. Despite LC being a common surgical procedure, it is not totally free from complications. These include cardiorespiratory problems, biliary leakage, peritonitis, hemorrhage and superior mesenteric artery (SMA) occlusion. We report an unusual and fatal complication of LC, being SMA thrombosis complicated by multiple intra-abdominal collections, abdominal compartment syndrome, multiorgan failure and septic shock.

INTRODUCTION

When Erich Mühe described laparoscopic cholecystectomy (LC) for the first time in 1985, the German medical society refused to agree with him.[1] However, within a few years, LC became the standard of treatment for gall bladder disorders.

Compared to open cholecystectomy, LC has various advantages which include shorter hospital stay, lower rate of complications and a reported mortality rate of less than 0.1%. Mortality is mainly due to biliary peritonitis, cardiorespiratory complications and superior mesenteric artery (SMA) thrombosis.[23]

We report a rare and fatal complication of LC, SMA thrombosis evolving to abdominal compartment syndrome (ACS), multiple intra-abdominal collection, multiorgan failure (MOF) and septic shock.

CASE REPORT

A 43-year-old male patient was admitted to the surgical ward with complaints of upper abdominal pain and colic of 1-day duration associated with vomiting and diarrhea. There was history of similar attacks in the past.

Upon admission, the patient was afebrile and hemodynamically stable. On examination, the right upper abdominal part was tender with positive Murphy's sign. A complete blood count (CBC) revealed leucocytosis (18 × 103/mm3), liver function tests (LFT) and electrolytes were normal. Ultrasound abdomen showed a gall bladder stone with signs of acute cholecystitis. The patient was treated with intravenous fluids, ceftriaxone, metronidazole and dalteparin (2500 international units subcutaneously twice daily).

Six hours after admission, the patient underwent a LC lasting 45 minutes. The gall bladder was edematous with a single stone and adhesions. Other abdominal organs were normal. Perioperative period was uneventful and the intra-abdominal pressure (IAP) varied between 12 and 15 mmHg. The histopathology report showed features of acute cholecystitis on top of chronic cholecystitis. Postoperatively, he recovered well and he was scheduled to be discharged 2 days post-LC.

On the day of discharge, the patient started to complain of new, severe epigastric pain. He was afebrile and vital signs were normal. A new CBC revealed severe leucocytosis (34 × 103/mm3). A computerized tomography (CT) scan [Figures 1 and 2] of the abdomen showed partial obstruction at the origin of the SMA with secondary ischemia of the small bowel resulting in an obstruction and dilatation of the proximal part of the small bowel. Due to the involvement of the small bowel, it was decided to manage the case surgically. Abdominal exploration revealed an ischemic terminal ileum, with good pulsation of the SMA. Resection and anastomosis of the ileum was done with a Bogota bag closure of the abdomen. The patient was transferred to the surgical intensive care unit (SICU) for further care. In the SICU, the patient was fully heparinized, intubated, sedated and ventilated. On day 4, a “second look” laparotomy was performed. The findings corresponded with a viable healthy bowel and no leakage at the anastomosis site. The abdominal wall was closed and heparinization was resumed after 6 hours. He was started on total parental nutrition. His echocardiogram was normal (no signs of embolism) and Doppler ultrasound of the lower limbs revealed no deep venous thrombus. He remained in sinus rhythm (no atrial fibrillation).

Figure 1

Thrombus causing partial blockage of superior mesentric artery

Figure 2

Thrombus in superior mesenteric artery

On day 12, the abdominal distension increased with an elevation of the IAP to 24 mmHg. His hemoglobin dropped to 6.3 g/dl for which he received blood and blood products. A CT scan of the abdomen on day 13 showed abdominal collections. On day 14, the patient's condition deteriorated. His abdomen was more distended; he required full ventilatory support and became oliguric with an elevation of the IAP to 25 mmHg. He was diagnosed as ACS and underwent decompressive laparotomy. A large amount of old and partially hemolysed blood-stained fluid collection was drained; the abdomen was closed by using a bagota bag. The patient remained unstable and needed inotropic support. On day 15, the patient became highly febrile (temperature of 39.2°C), developed septic shock and renal failure, and he was started on renal replacement therapy. On day 16, he went into asystole and died a few hours later.

Permission to publish this case report was obtained from the institutional research committee.

DISCUSSION

Erich Mühe et al. performed the first LC in the late 1980s.[1] Within a short period of time, LC became the operative treatment of choice for gall bladder surgery thanks to a lower complication rate and a shorter hospital stay as compared to the open cholecystectomy.[2] Because of these advantages, the number of patients undergoing LC increased tremendously in our institution up to more than 1000 per year. LC, however, is not free of complications either; these include technical complications, pneumoperitoneum and sequelae of general anesthesia. Mihály Ihász et al.,[3] reported in their study that fatal complications of LC include biliary peritonitis, cardiorespiratory failure and SMA thrombosis.[4]

Our patient presented with typical biliary pain and the diagnosis of calcular cholecystitis was confirmed by operative findings and histopathology report. The pain which started on the third postoperative day, was due to partial obstruction of the SMA (confirmed by CT scan), which was similar to earlier reports.[2-4]

Pressure controlled (12-15 mmHg) insufflations of the abdomen with carbon dioxide (CO2) is considered as an integral part of laparoscopic procedures in combination with an extreme patient positioning to allow surgeons a better visualization of the operative field. These pressure-controlled insufflations of the abdomen have potential adverse effects on the patient's physiology as it is known to decrease the venous return (preload), therefore lowering the cardiac output (COP) as well as mesenteric blood flow (stasis). An IAP as low as 10 mmHg in experimental animals demonstrated to have detrimental effect on COP and mesenteric blood flow.[5]

In our patient laparoscopic surgery was done according to the known standard procedure and the total duration of the surgery was 45 minutes. The postoperative course reflects a relief of the preoperative biliary colic and the patient was planned for discharge. On the second postoperative day, he developed severe pain due to an obstruction of the SMA. SMA thrombosis is a very rare fatal complication of laparoscopic procedures. Until now, only eight cases have been reported in the literature.[346] Most of these patients were having various risk factors for the development of thrombosis with pneumoperitoneum being considered the triggering factor for the development of SMA thrombosis.

Apart from decreasing the mesenteric blood flow, pneumoperitoneum is also known to decrease gastric mucosal pH (pHi), which is considered as an ischemic marker (low bowel perfusion) and which increases platelets aggregation.[7]

Our patient was unique, being young with no known risk factors for thrombosis/embolism (normal echocardiogram, no rhythm disturbances or atrial fibrillation or deep venous thrombosis).

We are aware of the possible percutaneous treatment for SMA thrombosis.[8] Due to the involvement of the small bowel in our patient, this was not feasible. Possibly, the intra-abdominal collections of old blood clots with decrease in hemoglobin concentration in our patient are due to oozing after the laparotomies and heparin infusion.[9]

We think that the initial dehydration in combination with the above mentioned effects of pneumoperitoneum (intra-abdominal hypertension) may have contributed to the development of acute SMA thrombosis. This was complicated by bowel ischemia, ACS, MOF and septic shock resulting in a fatal outcome.

CONCLUSIONS

SMA thrombosis is a rare but potentially fatal complication of pneumoperitoneum using the standard value of IAP of 15 mmHg, even if the patient has no obvious risk factors. We would suggest that all patients undergoing laparoscopic procedures need to be screened for the risk of thrombosis. They should also receive deep venous thrombosis prophylaxis and be well-hydrated. Finally, attending physicians should have a high index of suspicion for all possible complications of LC including SMA thrombosis, to limit the high reported associated mortality.