Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system. PRESENTATION OF CASE: A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely. DISCUSSION: Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure.
CONCLUSION: In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.