intrahepatic arterial aneurysms are rare and typically related to trauma , transplantation , iatrogenic injury , or infection
we present the case of a 49-year - old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy .
the aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy , which was performed laparoscopically .
. the diagnosis of hepatic artery aneurysm can be most readily made by mri or ct scan .
interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations . where indicated , surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice .
this is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium .
hemobilia , the phenomenon of bleeding into the biliary tree , from an intrahepatic aneurysm is an extremely rare occurrence .
hepatic artery aneurysms account for approximately 10% of hemobilia cases , and most are related to trauma , transplantation , surgical injury , or infection .
hemobilia caused by an intrahepatic arterial aneurysm is rare and presents a challenging medical diagnosis .
currently , several potential therapeutic options are available , including embolization , stenting , and resection .
the choice of treatment must consider the acuity of the bleeding and the anatomic location of the aneurysm as well as the underlying cause .
the role of laparoscopic liver resection in the treatment of a bleeding hepatic artery aneurysm has not been evaluated previously .
we report on a 49-year - old male with massive hemobilia , a recent laparoscopic cholecystectomy , a past medical history of hypertension , and a newly diagnosed aortic dissection .
we present the diagnostic approach , a review of the literature , and treatments for hemobilia caused by an intrahepatic aneurysm . in this case
a 49-year - old african - american male with abdominal pain and dark tarry stools was seen at a community hospital .
he had developed right upper quadrant pain and had passed several dark melanotic stools over 2 days .
hospital admission laboratory tests showed his hemoglobin and hematocrit were 5.3 and 16.8 , respectively .
he required transfusion of several units of packed red blood cells but remained hemodynamically stable .
an ultrasound demonstrated gallbladder sludge , stones , and thickening consistent with cholecystitis . within 72 hours of admission , the patient 's hematocrit became stable , and he did not require further transfusion .
postoperatively , the patient had further gastrointestinal bleeding with significant drops in hemoglobin and hematocrit requiring repeated transfusions .
he received 7 units of blood within 48 hours after cholecystectomy and was transferred to our hepatobiliary service for further treatment .
the ct scan revealed a previously undiagnosed aortic dissection beginning just distal to the left subclavian artery and terminating at the level of the left renal artery .
the scan also showed intrahepatic biliary dilatation and an accompanying left hepatic artery aneurysm with associated outpouching of the right portal vein that likely represented a venous varix ( figure 1a ) .
the mra showed a lobulated area in the left lobe of the liver , which measured 3 cm by 3 cm , highly suggestive of a portal venous varix ( figure 1b ) .
the options for treatment of the hepatic vascular / biliary abnormality included embolization by interventional techniques or hepatic resection .
the arteriogram and subsequent catheter placement were technically challenging , secondary to the aortic dissection with prominent false and true lumens .
the catheter was guided to the common hepatic artery and further to the left hepatic artery ; however , secondary to high - grade stenosis at the origin of the left hepatic artery aneurysm , the catheter could not be advanced , preventing embolization .
intraoperative ultrasound duplex was used to identify the location of the aneurysm with the left lobe of the liver .
the left portal vein and left hepatic artery were divided intrahepatically by using a 45-mm laparoscopic linear stapler , with 2.5-mm staples . ultimately , the left hepatic vein was isolated and similarly divided .
the specimen contained a large aneurysm with connection to the biliary system ( figure 2 ) .
the final pathology was consistent with an aneurysm that communicated with the biliary system and also demonstrated thrombi in adjacent portal vein tributaries .
a hepatic artery aneurysm is very rare but potentially life - threatening . of the visceral arteries most prone to true aneurysmal formation , the splenic and hepatic arteries are most common .
splenic and hepatic aneurysms account for 60% and 20% of all visceral artery aneurysms , respectively .
hepatic artery aneurysms may occur anywhere along the hepatic arterial system , both external to the liver and within the liver parenchyma .
seventy - seven percent of hepatic aneurysms are confined to the segment proximal to the liver , 20% have combined intra- and extraparenchymal involvement , and 3% are exclusively within the liver . excluding traumatic aneurysms ,
there is a male predominance ( approximately 3:2 ) . historically , most hepatic artery aneurysms have been mycotic in origin . today , nearly 50% of hepatic aneurysms
traumatic hepatic aneurysms typically result from either trauma ( car accidents ) or are iatrogenic , resulting from a diagnostic procedure .
the remainder is associated with medial degeneration and secondary atherosclerosis , with hypertension as the predominant comorbid condition .
interestingly , the populations most at risk for developing hepatic aneurysms are patients with fibromuscular dysplasia or polyarteritis nodosa .
decompression into the biliary tree with resulting hemobilia is more common than free rupture is into the abdominal cavity .
, hemobilia has increased in incidence , presumably secondary to increasing numbers of surgical and interventional radiologic procedures involving the liver .
the most common symptoms associated with hemobilia are jaundice ( 30% ) , biliary colic ( 52% ) , and gastrointestinal hemorrhage ( 73% ) .
the complete triad occurs in approximately 20% of symptomatic patients . once an upper gastrointestinal ( ugi ) bleed is suspected , endoscopy is the first - line diagnostic modality .
if blood or clot is seen at the ampulla of vater , hemobilia is highly likely .
however , only 12% of the upper endoscopies done to evaluate acute ugi bleeding are diagnostic .
radiologic studies , such as computed tomography , abdominal sonography , magnetic resonance , and angiography , are all potentially useful in identifying hepatic arterial abnormalities .
angiography can detect the source of significant hemobilia in over 90% of patients , allowing for localization of the vascular abnormality and possible therapeutic stenting or embolization .
the ultimate goal is to prevent or stop active hemorrhage and relieve any associated biliary obstruction . for extrahepatic aneurysm excision , arterial reconstruction or intraarterial stenting to affect aneurysm exclusion
embolization has a success rate of between 80% and 100% in some reports and a lower morbidity and mortality rate compared with that in open surgery .
if embolization fails or is contraindicated , surgical intervention , such as ligation of the artery or aneurysm excision , should be considered .
laparoscopic surgery for hemobilia caused by a hepatic artery aneurysm has not been described previously in the literature . in centers experienced in laparoscopic liver resection
, this approach adds an additional treatment modality . in our patient , laparoscopic resection allowed for complete removal of the aneurysm , preventing further bleeding or other potential complications that could result from a vascular - biliary fistula .
hemobilia secondary to intrahepatic aneurysm in a patient with newly diagnosed aortic dissection is a rare finding .
embolization is a first - line therapy for intrahepatic aneurysms but could not be accomplished in this case secondary to stenosis and anatomic limitations imposed by aortic dissection . in this case , laparoscopic left lobe resection provided definitive treatment without complications . increasing familiarity with laparoscopic liver resection in centers familiar with the techniques involved
 background : intrahepatic arterial aneurysms are rare and typically related to trauma , transplantation , iatrogenic injury , or infection . 
 they account for approximately 10% of clinically significant hemobilia.case report : we present the case of a 49-year - old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy . 
 the aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy , which was performed laparoscopically.discussion:evaluation of hemobilia requires a multidisciplinary team approach . 
 the diagnosis of hepatic artery aneurysm can be most readily made by mri or ct scan . 
 interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations . where indicated , surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice.conclusion:this is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium . 
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INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION