Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication

Table 1 Summary of risk factors associated to vascular injuries

Anatomical factors	Description
Common vascular variants of cystic artery and right hepatic artery	Single cystic artery[6]
	Two arteries (superficial and deep)[6]
	Single short cystic artery originated from caterpillar right hepatic artery[4,5,10]
	Long single cystic artery not from right hepatic artery crossing anterior to the common hepatic duct[7,8]
	Double cystic artery/accessory cystic artery[9]
	Cystic artery seen more anteriorly than posteriorly in relation to Mascagni’s lymph node[7,9]
	A constant vessel found on the postero-lateral margin of gallbladder bed[6,9]
	Cystic artery coming from gastroduodenal artery, passing outside Calot’s triangle[6,9]
Patient-related factors	Overweight and pathological obesity[1]
	History of biliary surgery or endoscopic procedures[1]
	Underlying liver disease[1]
Gallbladder pathology	Acute or chronic cholecystitis[1-3]
	Gallbladder anomalies (gallbladder duplication, gallbladder agenesia, left-side gallbladder)[1-3]
Surgical experience	Learning curve[1,2]
	Inadequate exposure[1,2,6]
	Failure to recognize anatomical landmarks[2,6]

Table 2 Classifications of vascular injuries during laparoscopic cholecystectomy

Ref.	Definition of vascular injury
Schäfer et al[29], 2000	Major injury: Injury to any of the following vessels: Aorta, vena cava, portal vein, hepatic artery and splenic artery, iliac vessels, mesenteric, omental and renal vessels; the vascular injury is classified in: Intra-operative; local haemorrhage within the abdominal cavity, retroperitoneum or abdominal wall; post-operative: Bleeding occurring within 24 h after surgery
Bektas et al[30], 2007	Vascular involvement in different biliary injuries grades (types C and D): Type C tangential injury of the common bile duct: with or without vascular lesion; Type D complete transection of the common bile duct: with or without vascular lesion
Kaushik[31], 2010	Major injury: Any bleeding involving cystic artery, right hepatic artery, portal vein, superior mesenteric vein, suprahepatic veins, inferior vena cava, aorta that requires conversion to open surgery to control/repair; additional surgical procedures; need for blood transfusions
Fingerhut et al[32], 2013	Vasculo-biliary involvement by reporting the type of injured vessel
Our study	Major vascular injury: Any bleeding involving right hepatic artery, portal vein, suprahepatic veins, inferior vena cava that always requires conversion to open surgery for control/repair; need for blood transfusions; associated biliary injury; need for transfer to tertiary center