title: Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy.
abstract: BACKGROUND
  Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear.
  
  
  METHODS
  Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship 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 the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately 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 cholecystectomy and should be identified preoperatively with ultrasound.
authors.affiliation: Department of Surgery, Jikei University School of Medicine, Tokyo, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Misawa
authors.forename: M
authors.initials: M
authors.lastname: Koike
authors.forename: K
authors.initials: K
authors.lastname: Suzuki
authors.forename: Y
authors.initials: Y
authors.lastname: Unemura
authors.forename: R
authors.initials: R
authors.lastname: Murai
authors.forename: K
authors.initials: K
authors.lastname: Yoshida
authors.forename: S
authors.initials: S
authors.lastname: Kobayashi
authors.forename: Y
authors.initials: Y
authors.lastname: Yamazaki
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D002763:Cholecystectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005704:Gallbladder / Q000000981:diagnostic imaging*; D006503:Hepatic Veins / Q000033:anatomy & histology / Q000293:injuries*; D006801:Humans; D007431:Intraoperative Complications; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011300:Preoperative Care; D012307:Risk Factors; D018615:Ultrasonography, Doppler, Color