If the bleeding is already controlled, and there is no availability for a surgeon with experience in HBP or cardiovascular surgery I think is better to reffer. 

On the other hand I think that you should prevent this. If the anatomy is not clear you should convert to laparotomy. In this scenario, if the hepatoduodenal ligament is severly  inflamed, especially in a chronic fashion, I think is safer an incomplete cholecistectomy, abandoning the gallbladder infundibulum. 

If you have a portal vein injury, more frequent are right branch injuries. In this case the referral is better.

In case of complete transection early repair is necessary. I am very curios about other answers. 

I'm completely agree with Professor Negoi.

Regards,

Giorgio Vasquez.

I would prefer to refer such a case after control of hemorrhage. And I agree with Dr. Negoi that one should be very careful to prevent this dire complication. 

 Chief surgeon made it, supplied the bleeding and called the doctor without experience after conversion to help. In this case decision to send the patient to referThere was a fast liver failure with a high INR and generalized bleeding before did transport the patient to referal center. Relaparotomy and packing after two hours. She was treated in intensif care unit by anestesiologists and died after 3 days. Expert says that a doctor should itself reconstruct the portal vein ( and bile ducts in a small hospital with no experience and equipment. . How many hours it can take and with what material (saphenous vein?)

Unfortunately we are facing severe liver ischemia with rapid progressive liver failure. In conclusion it was a lesion of the main portal vein, with complete occlusion (initial transection or secondary to hemostasis).

I think again that this injury should be prevented by careful dissection. Because, its management in a hospital without necessary resources is 100% deadly.

You need not only a very experienced surgeon, but also a very experienced Anesthesia& Intensive Care Unit. In my opinion, if this lesion is happened even in dedicated very high volume HPB centers, proximal and distal portal vein control in a such inflamed hepatoduodenal ligament needs massive blood transfusion and a massive transfusion protocol, together with a highly active Anesthesia team.

I think that the resected  portal vein segment should not be to long. According to this a direct end to end anastomosis with 5/0 Prolene should be possible, after adequate duodenopancreatic and liver mobilization. 

If the segment is longer: left renal vein, internal jugular vein or Dacron graft. 

As the repair should be done in less than 80 minutes, usually there is not enough time to harvest left renal or internal jugular vein. 

In this case Dacron prosthesis may be an option, if you have available one of appropriate size in you hospital.

A very interesting paper, coming I think from Paul Brousse,  described portal vein reconstruction using parietal peritoneum. I would like to test this in an experimental animal model.

In conclusion: for appropriate exposure a large Mercedes-Benz incisions, and an autostatic retractor, or two manual retractors to retract both costal margins, with sterile material attached to the head of the operating table.  

Large liver mobilization, Kocher and Cattell- Brach maneuvers, and an end-to-end repair. You should push the mobilized small bowel and duodeno-pancreas, and not to pull from the distal portal vein. Between the mobilized liver and the diaphragm two large surgical pads.

I agree with you professor Negoi. In that  situation 100% mortality ( complete excision from the duodenum to the liver to its surface after the split). Maybe fast  transport by helicopter and liver transplant. 

As you said only conversion to open cholecystektomy before problems is the solution. Thank professor Ionut Negoi and all for discussion. 

I think it is more relevant to ask why this critical and rare complication occurred in the first place. 

I do not have Idea why he did it. Excision is a fact. The question is what the not experienced general surgeon have  to do  in such difficult situations,  try to reconstruct the first time in my life or   send in spite of all the patient to a specialized  ( refaral) center? Is there anyone who treated that  case and with what results. Whether they is  reported case in literature. I can see only the paper, for example from Mayoklinic.

The surgeon who excise portal vein during lap cholecystectomy , should not be elegible to fix it . 

The guestion is: should he try to reconstruct (and of course patient will die on op. table) or control bleeding and try to reffer patient to tertiary center ( for example for transplantation )

Steven M Strasburg

HPB (Oxford). 2011 Jan; 13(1): 1–14.

doi:  10.1111/j.1477-2574.2010.00225.x

An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy

Steven M Strasberg1 and W Scott Helton2

In summary, an analytical review of VBIs revealed the following several findings. Right hepatic artery VBI is the most common variant. This injury is most likely to occur when the common hepatic duct is divided as described in the ‘classical’ injury during laparoscopic cholecystectomy. Injury to the RHA very likely extends the biliary injury to a higher level than the gross observed mechanical injury. Failures of bile duct reconstructions are more common when the bile duct is repaired in the early period after an RHA VBI has occurred because the bile duct is often ischaemic. Therefore, routine evaluation of the hepatic arteries is recommended in all patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Right hepatic artery VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the benefit of doing so has not been clearly demonstrated. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects. Rapid infarction of the liver is common in such injuries and patients should be emergently referred to tertiary centres where hepatopancreatobiliary expertise is available. The pathogenesis of such injuries is unclear. Pooling of data and standardized reporting of injuries should help to further delineate the consequences of injuries and, we hope, provide insights into their prevention.

The portal vein provides 60-70% of the oxygen to the liver.

Therefore, to prevent necrobiotic changes in liver surgeon must immediately use a temporary prosthesis to restore blood flow, for example, T-shaped carotid shunt or T-shaped silicone tube with a continuous introduction heparin in portal vein. (This will give time to the right decision.) Then transport the patient in a tertiary center.