Iatrogenic liver trauma managed with mesh-wrapping and ligation of portal vein branch: A case report

Abstract

Introduction

Liver trauma is a critical condition that requires swift multidisciplinary approach. In complex hepatic injuries perihepatic packing is an established life-saving procedure. The aim of this study is to evaluate and highlight the value of absorbable mesh wrapping of the injured liver, combined with ipsilateral ligation of portal vein branch.

Case presentation

An 82-year-old patient underwent an open cholocystectomy, for gallbladder empyema. The second postoperative day he was re-operated on due to active hemorrhage. The bleeding was controlled by suturing the bed of the gallbladder fossa. During this maneuver a portal vein branch was torn resulting in a rapidly expanding subcapsular liver hematoma which led to the formation of two deep lacerations on the liver parenchyma. This life-threatening condition was treated by wrapping an absorbable mesh around the right liver lobe and subsequently ligating the right portal vein branch extrahepaticaly.

Conclusion

Mesh wrapping of the fragmented liver with absorbable mesh constitutes a safe and effective method, in treating grade IV and V liver injuries, especially when combined with ipsilateral ligation of the bleeding vessel.

1. Introduction

The management of hepatic injuries has been considerably altered during the past two decades, requiring a multidisciplinary approach.¹ Non-operative management has become the treatment of choice in selected patients as a result of the advances in interventional radiology. Perihepatic packing is considered as a life-saving procedure for patients with complex hepatic injuries undergoing exploratory or staged laparotomy.^2,3 However, in cases where parenchymal liver fragmentation has occurred, packing cannot be effectively applied⁴ and the application of absorbable mesh material in clinical practice has significantly improved hemorrhage control in solid organs. Mesh wrapping of the liver, with or without concomitant gauze-packing, has improved the outcome of patients with liver trauma.

We present a case of a patient with an unusual iatrogenic liver trauma with multiple ruptures of the right liver lobe, manifested as a rapidly expanding sub-capsular hematoma. This life-threatening condition was controlled by a combination of mesh-wrapping and ligation of the right portal vein branch.

2. Case presentation

An 82-year-old male underwent open cholocystectomy for necrotic cholocystitis and gallbladder empyema. The second postoperative day the patient underwent an exploratory laparotomy for hemorrhage. The laparotomy revealed massive hemoperitoneum and a torn branch of the right portal vein in the gallbladder fossa was identified as the source of bleeding. The hemorrhage was controlled by application of two deep sutures at the edges of the gallbladder fossa. A drain tube was place in the Rutherford–Morrison pouch and soon after closing the abdominal wall, the anesthesiologists noticed sudden hemodynamic instability. The patient's blood pressure decreased to 70/60 mm Hg, while his heart rate reached 130 bpm. Severe metabolic acidosis resulting from lactic acid (5 mmol/L) accumulation was detected. At the time hemoglobin level was 6.5 g/dl. Immediate re-exploration of the abdomen was performed be the senior author (V.S.). A rapidly expanding sub-capsular hematoma was found, occupying the whole posterolateral aspect of the liver. Drainage of the hematoma revealed a big laceration between the right and left liver lobe, and multiple smaller separating the segments V, VII, VIII (Fig. 1). One and a half liter of blood were drained from the sub-capsular hematoma being fed from a torn branch of the right portal vein. A Pringle maneuver controlled the hemorrhage allowing access to the right portal vein branch laceration. Extra-hepatic ligation of the right portal vein was conducted in order to control the patient's hemodynamic instability. Right liver lobe fragmentation and stripping of its capsule, led us to control the hemorrhage by wrapping the right lobe with an absorbable mesh (BARD Hellas) in order to assemble the disrupted segments (Figs. 2 and 3). Gauze-packing was not performed as it seemed ineffective and probably more damaging, while de-packing would require reoperating. The right lobe was mobilized and rotated to the left. The mesh was sutured to the diaphragm on a vertical manner close to right diaphragmatic crus, starting from the right side of the IVC hiatus and ending down to the level of the right renal vein using a continuous Prolene 3–0 suture. The mesh was pulled over the surface of the right lobe taking care to be sufficiently tight in order to exert compression on the liver parenchyma, and was finally anchored to the falciform ligament. (Fig. 4)

Fig. 1.

Hematoma within the right liver lobe.

Figs. 2 and 3.

The mesh is wrapped around the right liver lobe and sutured on the falciform ligament and the right diaphragmatic crus, in order to tamponade the traumatic liver parenchyma.

Fig. 4.

Post operative computed tomography scan of the liver (big dotted arrow: drain placed posteriorly to the right liver lobe mesh wrapped around right liver lobe; small dotted arrow: injury to the right portal vein branch, which was extra-hepatically ligated; white arrows: mesh placed under tension creating a tamponade effect).

The Pringle maneuver was released and no hemorrhage was noticed over the mesh wrapped liver except of a mild oozing. The patient gained gradually hemodynamic stability. At the end of the operation a subphrenic drainage was placed. The postoperative course was uneventful. The patient was extubated on the third postoperative day and was discharged on the 13th postoperative day. Hepatic function was restored as confirmed by liver enzyme levels and ultrasonography.

3. Discussion

Over the past two decades novel refinements in the management of complex hepatic trauma have been established.⁵ Conservative management based on close hemodynamic monitoring, interventional radiology methods and angiography has been the method of choice in high grade hepatic injuries.² However, when exploratory laparotomy is performed the management of these injuries is still challenging. Gauze-packing, remains in the majority of patients an effective method of hemostasis for major liver trauma. However, it is not always easily applicable and needs de-packing.⁶ Furthermore, removal of the gauzes may be complicated with recurrent bleeding and stripping of the liver capsule due to adhesion to the packing material. Mesh wrapping constitutes a safe and effective method providing hemostasis by a tamponading effect. It was first introduced by Buntain and Lynn to control splenic hemorrhage.⁷ Mesh wrap has been used to control liver bleeding in grafts that have been damaged during transplantation.⁴ In our case, mesh wrapping of the fragmented liver was combined with ligation of the ipsilateral portal vein branch, because the bleeding-source was identified close to the tributaries of the right portal vein. Resection of the fragmented right lobe could be an alternative option. However the hemodynamic stability of the patient did not allow a major operation. There are reports especially in cases of fragmented livers treated successfully by resorting to wrapping technique with or without additional gauze-packing.⁸ Emphasis should be given in two important technical aspects of the mesh wrapping technique. First, the traumatized liver has to be slung with the mesh under enough tension to create a tamponade effect. In addition the mesh should be attached into two anchoring stable points. The diaphragmatic crus and the falciform ligament provide the best options to stabilize the mesh.

Furthermore the resulting product of mesh hydrolysis has a bacteriostatic effect, minimizing the risk of infection.⁹ In our case the patient responded excellently to ipsilateral portal branch ligation with fast recovery of a major operation. Liver enzyme and lactic-acid blood levels were within normal range. As far as the cause of the complication is concerned, we presume that the sub-capsular suturing of the gallbladder fossa tore the right branch of the portal vein and the hematoma was vented through the intrasegmental plain into the sub-capsular space.

4. Conclusion

In conclusion wrapping with an absorbable mesh a traumatized and disrupted liver seems to be a rapid and effective method in controlling bleeding, combined with ligation of the vessel feeding the hemorrhage if achievable. Furthermore – when necessary – classical gauze-packing becomes easier and more effective.

Conflict of interest statement

The author(s) declare that they have no competing interests.

Funding

None.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.