A 60-Year-Old Man with an Incidental Finding of an Asymptomatic Aneurysm of the Right Gastroepiploic Artery Managed by Laparoscopic Resection

Introduction

Splanchnic artery aneurysms are rare. In postmortem studies, gastroepiploic artery aneurysms account for approximately 1% of all splanchnic aneurysms [1,2]. The highest incidence is observed in the splenic artery, followed by the hepatic, superior mesenteric, and celiac arteries. Gastric and gastroepiploic aneurysms account for 3% of reported cases. They are 3 times more common in men than in women [2]. Gastroepiploic artery aneurysms alone account for 0.4%. They are more frequently identified in the right gastroepiploic artery than in the left [3]. This could have resulted from the larger diameter of the right vessel. The causes of gastroepiploic aneurysms include arteriosclerosis, trauma, surgery, fibromuscular dysplasia, polyarteritis nodosa, antineutrophil cytoplasmic antibody-associated vasculitis, giant cell arteritis, Takayasu arteritis, Behcet disease, Kawasaki disease, Ehlers-Danlos syndrome type IV, Marfan syndrome, neurofibromatosis, pseudoxanthoma elasticum, inflammation, infection, and segmental arterial mediolysis [4–7].

Despite the low incidence of gastroepiploic aneurysms, 70% of affected patients die when rupture occurs [2]. Thus, the appropriate treatment is essential in asymptomatic patients. The symptoms of gastroepiploic aneurysms include abdominal pain, palpable masses, gastrointestinal bleeding, hemoperitoneum, and hemorrhagic shock. However, most aneurysms remain asymptomatic.

The diagnosis is established through Doppler ultrasonography, angiography, magnetic resonance angiography, and contrast enhanced computed tomography (CT) [8]. All imaging modalities enable precise measurement of aneurysmal dimensions and detection of potential endoleaks. Doppler ultrasonography can additionally reveal blood flow within the identified lesions, providing functional assessment alongside morphological evaluation. CT can also offer 3-dimensional (3D) reconstructions, which can be valuable in planning the treatment strategy.

There are 3 methods of gastroepiploic artery aneurysms management: open surgery, endovascular, and laparoscopic procedures [8]. Open surgery procedures include excision and ligation of the aneurysm, ligature of the supplying artery, and resection of the aneurysm with direct end-to-end anastomosis [9,10]. Anastomosis can also be performed within the saphenous vein graft, dacron, and polytetrafluoroethylene graft [9]. Open surgery procedures are mainly performed in cases of life-threatening hemorrhage due to rupture of visceral aneurysms. Other factors favoring the choice of the classic open surgery approach is definitive repair, tortuous course of supplying artery, size of aneurysm, full range of treatment options, and assessment of bowel viability [10]. Open surgery procedures are associated with complications such as graft occlusion, ischemia of related organs, intra-abdominal abscess, gangrenous cholecystitis, a duodenal leak, short gut syndrome, and deep venous thrombosis of the lower extremities [9,11].

Endovascular techniques should be considered in symptomatic patients who are at a high surgical risk due to comorbidities [12]. Those who underwent previous abdominal interventions and have had pancreatitis should be treated using the endovascular approach. Aneurysms involving the second- or third-order branches of the main visceral arteries and small aneurysms with a narrow neck are suitable for these techniques. Endovascular options include coiling, covered stent exclusion, thrombin injection, gluing, plug deployment, particle injection, and polyvinyl alcohol injection [13]. Embolization is typically preferred for aneurysms within solid organs [14]. Covered stent placement can be preferred to preserve the parent artery when the main visceral vessels are treated [14]. Complications of endovascular techniques involve aneurysm rupture, coil migration, dissection of the visceral artery, recanalization, end-organ ischemia, and stent thrombosis [10,15–17].

Laparoscopic repair is a minimally invasive alternative to open surgery and is associated with decreased pain and a shorter hospital stay than classic surgical procedures [18]. Little is known about the outcomes of laparoscopic management of visceral aneurysms, particularly those arising from gastroepiploic arteries [19,20]. The ligation of the arteries supplying the aneurysm could be performed with the Endo-GIA stapler or Hem-o-lock clips. In one case, the surgeons decided to perform a double aneurysmectomy en bloc with excision of the adjacent greater curvature of the stomach using an articulated laparoscopic stapler [21]. Laparoscopic management can result in aneurysm rupture, leading to conversion to open surgery. Inadvertent damage to organs supplied by arteries connected to aneurysms or damage to organs, such as the pancreas, could be other indications for conversion to open surgery. Laparoscopic procedures are associated with typical complications, such as hypercarbia, acidosis, cardiovascular compromise with abdominal insufflation, and air embolus [10].

This report describes the case of a 60-year-old man with an incidental finding of an asymptomatic aneurysm of the right gastroepiploic artery that was managed by laparoscopic resection.

Case Report

A 60-year-old man underwent a follow-up ultrasonography of the kidneys in the outpatient clinic, which incidentally revealed kidney cysts. Radiologists suggested CT to confirm the morphology, number, size, and localization of the renal cysts. Then, a CT scan of the abdominal cavity was conducted on June 5 outside our center, and an aneurysm of the right gastroepiploic artery was diagnosed. The CT scan revealed the aneurysm measured 11.5×7×6 mm and was located in a branch of the right gastroepiploic artery at the great curvature of the stomach (Figures 1, 2). The aneurysm was located on the antero-pyloric wall of the stomach at a distance of 11 mm from the stomach and 7 mm from the visceral surface of the left lobe of the liver, which is situated in the median line of the body, approximately 44 mm downward from the palpable end of the xiphoid process, and at a depth of 25 mm from the skin surface. A control CT scan (on September 10) showed no progression of the aneurysm and excluded rupture or bleeding. The morphology and size of the aneurysm were unchanged, compared with previous examinations.

The patient was admitted to the Department of General and Transplant Surgery to manage an aneurysm of the right gastroepiploic artery. On admission, the abdomen was soft and non-tender on clinical examination. No signs of peritonitis were noted. The patient did not report any clinical symptoms of aneurysm, such as abdominal pain. History of bleeding from the upper and lower gastrointestinal tract was negative. The patient did not undergo an endoscopy of the upper gastrointestinal tract. Peristalsis was normal. Peripheral blood morphology and coagulation parameters, including international normalized ratio and activated partial thromboplastin time, were normal. In the past, the patient underwent hernia repair of the linea alba, 2 right shoulder operations, ablation due to atrial fibrillation, implantation of a pacemaker due to tachy-brady syndrome, and laser therapy of the left eye due to retinal detachment. Laboratory test results revealed no abnormalities. He had hypertension, atrial fibrillation, dyslipidemia, and obesity. The patient was taking rivaroxaban long-term. History of vascular disease, collagen synthesis disorders, and presence of aneurysms in other locations was negative.

Based on the CT scan and considering our experience with gastric surgery, we proposed laparoscopic resection of the aneurysm as the definitive form of treatment. Before the invasive procedure, we performed a 3D reconstruction of the lesion to confirm the size and localization. The reconstruction was based on the CT images from September 10, 2024 (Figure 3). The patient provided a written informed consent.

The operation was performed under general anesthesia. The patient was placed in an anti-Trendelenburg position. Peritoneal emphysema was created after the placement of the Veress needle at the Palmer point. The abdomen was insufflated with carbon dioxide at 10 mm Hg. The trocar insertion site was injected with 1% lidocaine. After the creation of peritoneal emphysema, in the median line in the epigastrium, a Visiport was inserted under optic control, and then further trocars were inserted under optical control: 10 mm in the left epigastrium, 12 mm in the right epigastrium, and 5 mm extreme laterally on the right and left sides. The liver was suspended using a retractor. The preparation proceeded, making the aneurysm sac visible (Figure 4). The gastroepiploic artery was then dissected proximal and distal to the aneurysm, and 3 Medtronic Endo Clip Auto Suture clips were placed on each side (Figure 5A, 5B). The aneurysm sac was separated from the gastroepiploic vein and severed (Figure 6). Hemostasis control was ensured (Figure 7). The liver hook was removed. Trocar sites were inspected and showed no bleeding. The peritoneal emphysema was released. Single sutures were placed in the wounds, and sterile dressings were applied. The entire procedure lasted 45 min.

The operative and postoperative periods were uncomplicated, no signs of bleeding were noted, and hemoglobin concentration was stable. Pain was well controlled. The patient was discharged from our surgical ward the following day in good general condition.

Discussion

No definitive treatment guidelines are available for the management of asymptomatic visceral aneurysms. Surgical treatment is indicated when the aneurysm diameter is greater than 2 cm, when identified during pregnancy, when multiple aneurysms are present, and in the case of hepatic transplantation [7]. Conservative management is reasonable for most asymptomatic aneurysms less than 2 cm [7]. The management options for visceral aneurysms include open surgery, laparoscopic, and endovascular techniques.

In the presented case, an asymptomatic aneurysm was resected due to the high mortality associated with ruptured gastroepiploic artery aneurysms. A laparoscopic approach was chosen based on its well-established minimally invasive profile. However, the symptomatology, diagnostic process, and laparoscopic technique in our case differ from those described in previous reports. In earlier cases, patients typically presented with symptoms such as a pulsatile, movable mass [20] or acute epigastric pain [21,22]. In one previously reported laparoscopic case, the aneurysm was diagnosed incidentally during a follow-up examination after pituitary gland surgery [19].

In our case, the diagnosis was established using contrast-enhanced CT. Prior to determining the optimal treatment strategy, a preoperative 3D reconstruction was performed to accurately assess the aneurysm’s location and vascular supply, thus facilitating safe surgical planning and execution. Angiography was not performed. In contrast, other authors have used angiography to visualize the blood supply of aneurysms initially detected through noninvasive imaging modalities such as Doppler ultrasonography or CT. They also used 3D reconstructions in their preoperative evaluations [19–22].

In earlier reports and in our case, the decision to proceed with laparoscopic surgery, rather than open or endovascular intervention, was guided by the superior visualization of the aneurysm and the potential for definitive treatment. In one reported case, laparoscopy was selected due to the infeasibility of endovascular management [21].

Because the aneurysm in the present case was asymptomatic, the procedure could be scheduled electively. The technique used was analogous to that employed in sleeve gastrectomy, allowing optimal visualization and safe resection of the lesion. In our opinion, this method may be particularly advantageous for aneurysms located along the greater curvature of the stomach. Moreover, it significantly reduced the operative time, which in our case was 45 min – substantially shorter than times reported in the current literature [20,21]. Previous descriptions of laparoscopic management of gastroepiploic artery aneurysms have included a single-incision laparoscopic approach in cases of aneurysm rupture [22], as well as multiport techniques: one with 3 trocars (placed above the umbilicus, in the left upper quadrant, and in the left lower quadrant) [20], and another using 5 trocars (1 umbilical port and 4 additional ports placed in the upper abdomen – three 5-mm ports under the bilateral costal margin and on the right side of the umbilicus, and a 12-mm port on the left side of the umbilicus) [21]. In all cases, the postoperative course was uneventful.

Conclusions

In this report, we have described a rare case of asymptomatic aneurysm of the right gastroepiploic artery that was successfully managed laparoscopically. Laparoscopic management of gastroepiploic artery aneurysms could be a safe option for asymptomatic and non-ruptured lesions. It could be considered in tortuous arteries and in patients with obesity or multiple comorbidities. This laparoscopic approach ensures definitive treatment. In our case, we emphasize the need for 3D reconstruction with direct localization of the aneurysm prior to the procedure. We recommend typical sleeve gastrectomy trocar localization. In our opinion, this allows a full perspective of the large curvature of the stomach, which prevents damage to adjacent organs and rupture of aneurysms. This case report introduces a novel approach to the treatment of splanchnic artery aneurysms, with the aim of making the procedure as routine as cholecystectomy or laparoscopic hernioplasty.