Surg Today (2002) 32:840–843

Laparoscopic Cholecystectomy After Coronary Artery BypassGrafting Using the Right Gastroepiploic Artery: Report of a Case

Kazuhiro Sakamoto1, Masayuki Kitajima1, Tsuyoshi Okada1, Shigeru Shirota1, Mitsuhiro Matsuda1,Suguru Watabe1, Yoshifumi Lee1, Yuichi Tomiki1, Shigeru Kobayashi1, Toshiki Kamano1,Masahiko Tsurumaru1, and Kenji Takazawa2

1 First Department of Surgery and 2 Department of Thoracic Surgery, Juntendo University, School of Medicine, 2-1-1 Hongo, Bunkyo-ku,Tokyo 113-8421, Japan

there is a possibility of injuring the graft during subse-quent abdominal operations. Even a relatively simpleprocedure, such as a cholecystectomy, can thus becomerisky and complicated.3 A laparoscopic cholecystectomy(LC) has rapidly become the treatment of choice forgallstones since the introduction of LC.4 Recently,laparoscopic surgery has also been applied more widelyfor the treatment of various gastrointestinal diseases.We herein describe a patient who successfully under-went LC after CABG using the RGEA.

Case Report

A 61-year-old man underwent CABG on October 15,1998. The diagonal artery was grafted to the left internalthoracic artery and the right coronary artery wasanastomosed to the RGEA. Gallstones were detectedpreoperatively, but he had no symptoms. The earlypostoperative course was uneventful and he was dis-charged 13 days after CABG. However, he developedright hypochondralgia after being discharged and pre-sented on November 4, 1998. After examination, chole-cystitis with gallstones was diagnosed and was treatedconservatively. Although he recovered and remained ingood health, he wished to be free from abdominal pain.He was therefore admitted to our department to un-dergo a cholecystectomy on August 29, 1999. On admis-sion, his abdomen was soft and flat with no tenderness.The median sternotomy scar extended to just below themidpoint between the xiphoid process and the umbili-cus. Preoperative laboratory tests showed the transami-nase, biliary enzyme, and bilirubin levels to be normal.Ultrasonography (US) showed small stones in thegallbladder (Fig. 1). Magnetic resonance cholangio-pancreatography (MRCP) revealed no filling defects ora dilatation of the bile duct. Coronary angiography wasperformed after CABG and demonstrated a good bloodflow from the RGEA to the right coronary artery (Fig.

AbstractA laparoscopic cholecystectomy (LC) was successfullyperformed on a 61-year-old man who had undergonecoronary artery bypass grafting (CABG) using theright gastroepiploic artery (RGEA). He complained ofright hypochondralgia 20 days after CABG. Gallstoneswere diagnosed and a cholecystectomy was performed 9months after CABG. Under general anesthesia, theoperation was performed using a pneumoperitonium.When a laparoscope was inserted, the RGEA pediclecould be clearly recognized. The pedicle obstructed theoperating field and made the working space narrowerthan usual. No ST changes on the electrocardiogramwere seen during LC, especially during the initiation ofpneumoperitonium, the insertion of the ports, or whenretracting the gallbladder. The postoperative coursewas uneventful. To avoid complications, care should betaken not to stretch the RGEA pedicle during LC,and careful monitoring of the electrocardiogram is alsonecessary. It is difficult to view the operating field andthe RGEA pedicle together. It is therefore better toinsert another laparoscope for concomitant monitoringof the RGEA pedicle.

Key words Laparoscopic cholecystectomy · Gallstone ·Coronary artery bypass grafting

Introduction

The right gastroepiploic artery (RGEA) has recentlybeen recognized as a suitable conduit for coronary ar-tery bypass grafting (CABG) as well as the internalthoracic artery because of its good patency.1,2 However,

Reprint requests to: K. SakamotoReceived: June 25, 2001 / Accepted: January 8, 2002

841K. Sakamoto et al.: Laparoscopic Cholecystectomy After Coronary Bypass

2). The final diagnosis was gallstones, and a cholecystec-tomy was thus indicated.

On September 9, 1999, the operation was performedunder general anesthesia using intermittent sequentialcompression of the lower extremities, with cardiacsurgeons on standby in case of ischemia or an injury tothe RGEA pedicle. The first laparoscope port wasplaced in the infraumbilical region by an open laparo-tomy. Next, the abdomen was filled with CO2 and the

pneumoperitonium pressure was kept at 5 mmHg with-out any ST segment changes on the monitored electro-cardiogram. A 30° laparoscope was inserted through theport and it showed the whole RGEA pedicle clearly,because it had been placed anterior to the stomach andbrought through a hole in the right anterior part of thediaphragm to the left of the porta hepaticus. Thereafterthe pneumoperitonium pressure gradually increased to8mm Hg, but there were no changes on the electrocar-diogram findings. The RGEA pedicle adhered to thegreater omentum and transverse colon, blocking a di-rect view of the gallbladder. However, we consideredthat laparoscopic surgery was still possible, so threeother ports were created. We were especially carefulwhen placing the second port, which was in the uppermedian epigastric region. It was placed slightly to theright of the usual site, because the RGEA pedicle ad-hered to the left side of the porta hepaticus. Whilethis port was being inserted, we carefully observed thepedicle to ensure that it was not stretched. We thenstarted to perform the cholecystectomy. When the gall-bladder was retracted toward the diaphragm, there wasno ST segment depression on the electrocardiogram.First, the cystic duct was dissected, but this was found tobe very difficult. Since its pedicle adhered to the greateromentum and the transverse colon, the operating fieldof the laparoscope and the working space for thelaparoscopic forceps were narrower than usual (Fig. 3).The cystic duct was carefully dissected out, and cut afterperforming intraoperative cholangiography. Next thecystic artery was clipped and cut. After the liver bed wasdissected, the resected gallbladder was removed fromthe abdominal cavity using a retrieval bag. When weobserved the liver bed, bleeding was recognized and asponge was pressed onto the site for about 30min. Afterthe application of fibrin glue, the bleeding was con-trolled. A drain was placed near the liver bed. Theduration of the operation was 170min. There were noelectrocardiographic signs of ischemia during LC, andthere was also no evidence of myocardial ischemia, in-cluding cardiac enzyme elevation, after the operation.The patient was discharged on the sixth postoperativeday.

Discussion

The RGEA is an excellent conduit for coronaryrevascularization and has a good long-term patencysimilar to that of the internal thoracic artery.1,2 Signifi-cant luminal narrowing caused by arteriosclerosis israre in both arteries.5 However, patients who undergoCABG with the RGEA have a risk of injury to thepedicle during subsequent abdominal operations. Evena relatively simple procedure, such as a cholecystec-

Fig. 1. Ultrasonogram demonstrating small stones in thegallbladder

Fig. 2. Coronary angiography after coronary artery bypassgrafting demonstrating a good blood flow from the right gas-troepiploic artery (RGEA) (arrows) to the right coronaryartery

842 K. Sakamoto et al.: Laparoscopic Cholecystectomy After Coronary Bypass

tomy, may thus become a high-risk and complicatedoperation. Terada and Suma6 reported a combined sur-gical procedure involving CABG and cholecystectomy,which was done even if the gallstones were asymptom-atic, because it is reported that about 15%–50% of si-lent gallstones become symptomatic within 5 years.7,8

Moreover, the RGEA pedicle may also cause problemsduring future cholecystectomies. Therefore, we agreethat a combined CABG and cholecystectomy shouldbe performed in such cases. Although a successfulcholecystectomy was performed laparoscopically in thiscase, we should have done the CABG using the RGEAand cholecystectomy simultaneously. Especially duringLC, we should be careful to ensure that bile leakagedoes not lead to the occurrence of mediastinitis andother infections. However, such patients may still needa laparotomy later in life for other abdominal diseases.

When a cholecystectomy is done in patients whohave undergone CABG using the RGEA, we shouldtake note of the following points. First, it is necessaryto determine the anatomical orientation of the RGEApedicle whether the operation is a laparoscopic pro-cedure or an open procedure. There are two possibleroutes for a RGEA graft, including the antegastricroute and the retrogastric route. Most cardiac sur-geons employ the antegastric route because it allows aneasier identification of any bleeding from the RGEApedicle. Second, we should be careful to ensure thatthe RGEA pedicle is not stretched or injured duringthe operation. Even if the RGEA pedicle is not injured,traction may disturb the blood flow and cause myo-cardial ischemia. The ST segment depression in leadsII, III, and aVF has been detected on electrocardio-gram findings when retractors were applied during

Fig. 3a–d. Operative findings. a, b Laparoscopy showing thewhole RGEA pedicle (arrows). Its pedicle is placed clearlyanterior to the stomach and passes through a hole in the

diaphragm on the left of the porta hepaticus. c The gallbladderis retracted toward the diaphragm. d Dissection around theneck of the gallbladder

a

c

b

d

843K. Sakamoto et al.: Laparoscopic Cholecystectomy After Coronary Bypass

an open cholecystectomy after CABG using theRGEA.6

Pol et al.9 reported a successful laparoscopic cholecys-tectomy after CABG using the RGEA. In addition,when initiating the pneumoperitonium, inserting theports, and retracting the gallbladder it is important tomake sure that ischemic changes do not occur due tostretching of the RGEA pedicle. If ischemic ST changesoccur during such a procedure, we can convert to anopen procedure from LC. We also recommend a sub-costal approach, which minimizes a risk of the RGEApedicle injury. We could see the whole RGEA pedicleclearly at laparoscopy. Laparoscopic observations al-lowed us to recognize the anatomical orientation of thewhole pedicle, which may also be seen more clearly thanwith open procedures. Moreover, a laparoscopy can beeasily performed even when using a lower pneumoperi-tonium pressure (such as 5 mmHg).

During LC, it is difficult to visualize the operatingfield and the RGEA pedicle together. It is thereforenecessary to move the laparoscope frequently in orderto alternately view the RGEA pedicle and the operatingfield. Especially during a dissection of Calot’s triangle, itis necessary to ensure that the pedicle is not stretched,since the pedicle impinges on the operating field andmakes it narrower than usual. As a result, it is beneficialto use another laparoscope for the concomitant moni-toring of the RGEA pedicle.

Conclusion

Laparoscopy can visualize the whole RGEA pedicle. Itis necessary to carefully monitor the electrocardiogram

during surgery to ensure that no ischemic changes oc-cur. It is difficult to visualize the operating field and theRGEA pedicle together during LC, and therefore it isbetter to insert another laparoscope for the concomi-tant monitoring of the pedicle.

References

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