Comment to: Vuilleumier H, Halkic N. Ruptured subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac-induced coagulopathy. Surg Endosc 2006, online first

Abstract

The contribution of Vuilleumier and Halkic makes us aware that bleedings during or after laparoscopic cholecystectomy can be life-threatening [1], the clinical endpoint being that ketoralac-induced coagulopathy can be the cause of intra/postoperative bleeding after laparoscopic cholecystectomy. The authors note the need for an inciting factor to trigger this bleeding, and provide a solution in minor trauma to the liver bed. The inciting factor can be an anatomic variation. Arterial anastomoses between the cystic artery and the arterial system of the liver occur in 12% cases. Their mean length is 18.3 mm (range 4–60), and mean diameter is 0.38 mm (range 0.2–0.8). These arterial anastomoses bleed from both ends and are located in the liver bed [2, 3]. After division, the hepatic end of the anastomosis retracts into the hepatic tissue. Because of this retraction, no active arterial bleeding is noticed during the procedure. Dissimilarly, bleedings from other vessels during laparoscopic cholecystectomy are noticed while inspecting the liver bed or rinsing it with saline. Continuous bleeding from the hepatic end of this anastomosis results in the intrahepatic hemathoma. Nonsteroidal anti-inflammatory drugs (NSAIDS) [1] can only facilitate such bleedings but cannot be their cause. They can, however, be the reason for prolonged bleeding and subsequent rupture of the hemathoma.