Rare Encounter with Anomalous Vein in Gb Fossa During LC

Rare encounter with anomalous vein in GB fossa during LC Abstract. The short video & few pictures added in the video is not an operative video per se but an attempt to showcase a surgical conundrum faced during a laparoscopic cholecystectomy. Unfortunately it could not be recorded in a recording device for technical failure & the video was taken in a mobile from the monitor screen and so were the photos. However the findings of this short video is worth sharing with others for inherent danger of misidentification or non-identification of an unusual structure I encountered in the gall bladder bed. This was a routine laparoscopic cholecystectomy planned for symptomatic gall bladder stone disease in a middle aged patient with normal blood parameters including LFT & finding of multiple gall stones without wall thickening in ultrasound. Procedure was performed in the routine fashion with a relatively easy dissection of callot’s triangle. Cystic duct cystic artery dissected and identified beyond doubt & divided. So far everything looked normal. But once I started dissecting the gall bladder infundibulum from the liver bed, an ominous looking bulging thin walled bluish structure started appearing in the liver bed in very close proximity to the posterior wall of gall bladder without any discernable plane of dissection between them. I was using diathermy hook so far for dissecting the GB from its bed, but seeing the unusual bulging cystic bluish structure in the gall bladder bed & in very close proximity to the GB wall, I stopped using diathermy & contemplated what the structure could be? It looked bluish, just like a non-inflamed GB looks. Its dimensions in size was comparable to a normal gall bladder. It was compressible as was demonstrated by the sucker tip. With an initial impression of a possible double gall bladder I proceeded with blunt dissection with sucker tip as the gall bladder was in close apposition to this unusual blue cystic structure at its bed. As there was no stigma of chronic inflammation the blunt dissection was easy with little oozing only. When the infundibulum was separated from its liver bed I could see the blue structure has become somewhat smaller & giving rise to two straight veins of significant size. (Short video starts at this point) The common trunk of those two veins was so distended before that it looked like a cystic blue structure. With further dissection continued towards the fundus the linear courses of the two big venous branches became obvious. Throughout the length of the GB those veins were in intimate contact with the posterior wall of gall bladder. The more dissection progressed towards the fundus of the GB the common venous trunk & two divisions of it became less engorged, the fundal & infundibular traction was causing pressure effect on the veins for them to distend very significantly. When the gall bladder was finally removed the veins collapsed significantly. The picture of GB bed after complete removal of the GB shows the veins in its bed. The cystic plate of surgical dissection was nonexistent here. From the direction of flow of blood through those veins it is obvious they were radicles of right branch portal vein in very superficial position. At least that is my understanding. In laparoscopic cholecystectomy the separation of GB from its liver bed is the only time when a surgeon can relax a little bit, but after encountering this I won’t be so in future. Many incidences of severe venous bleeding has been encountered by surgeons & often termed as bleeding from venous sinuses of liver parenchyma. Catastrophic sinus bleed have also found mention in literature. I just wonder if some of those catastrophic ‘sinus bleed’ were in fact bleeding from such superficial portal venous radicles? Take home message from this poor quality video is very rich. Surgeon needs to remain alert even when the gall bladder is dissected from its liver bed after successful & safe completion of the difficult bit, the dissection of hepatocystic triangle. Danger lurks everywhere in laparoscopic cholecystectomy for anatomical variations are varied & unlikely to be picked up during routine pre-operative investigations