Emergency hand-assisted laparoscopic haemostasis for post-operative haemorrhage following laparoscopic liver resection.

INTRODUCTION: The use of laparoscopic surgery for liver resection and the management of abdominal emergencies has been well established. However, the value of this technique for post-operative haemorrhage in liver resection has not been characterized. CASE DESCRIPTION: We describe a case of post-operative haemorrhage following an elective totally laparoscopic liver resection that was treated with emergency hand-assisted laparoscopic haemostasis. DISCUSSION: Emergency hand-assisted laparoscopic haemostasis in the setting of post-operative haemorrhage after laparoscopic liver resection is feasible and should be considered as a treatment option in suitable patients.

Post-hepatectomy haemorrhage (PHH) is a well-known complication of liver resection, with a reported incidence of 0%–3% in laparoscopic liver resection (LLR).[1] In general, PHH requires either endovascular therapy or reoperation to arrest the bleeding. In the case of reoperation, this is classically performed through re-laparotomy. Growing expertise in laparoscopic surgery, however, has seen the increased use of minimally invasive surgery to treat surgical emergencies including intra-abdominal bleeding.[2] Here, we describe, to the best of our knowledge, the first description of emergency hand-assisted laparoscopic haemostasis for PHH after LLR.

A 29-year-old female with no medical history presented with right lower quadrant pain and was admitted to the hospital for suspected acute appendicitis. Computed tomography (CT) of the abdomen and pelvis demonstrated an incidental 5 cm mass located in segment VI of the liver with no features of appendicitis. Serum hepatitis B and C serology and tumour markers including alpha-fetoprotein, carbohydrate antigen 19-9 and carcinoembryonic antigen were within normal limits. The pain resolved and she was discharged. An early Magnetic resonance imaging of the liver showed a 5 cm hypervascular mass in segment VI. The case was discussed at our hepatobiliary multidisciplinary meeting and the consensus was that the lesion was either focal nodular hyperplasia (FNH) or adenoma.

The findings were discussed with the patient and she agreed for and subsequently underwent elective totally laparoscopic resection of the segment VI liver tumour. The patient was placed supine and a 12 mm supraumbilical port for the laparoscope, another 12 mm epigastric port, and a 5 mm right hypochondrium port were inserted. Intra-operative examination revealed an exophytic liver tumour in segment VI of the liver. There were mild adhesions in the right iliac fossa, with part of the small bowel adherent to the anterior abdominal wall. Parenchymal transection was performed with LigaSure (Covidien, Boulder, CO, USA). The vascular pedicle was transected using the Endo-GIA™ Tri-Staple™ 45 mm vascular reload. Total operation time was 70 min with negligible blood loss. The umbilical port was extended to 3 cm and the specimen was extracted in a bag.

Post-operatively, the patient was monitored in a high dependency unit. Five hours after surgery, she developed hypovolemic shock, including tachycardia (pulse rate 111), hypotension (blood pressure 78/44 mmHg) and low urine output. Urgent haematological investigations showed a drop in haemoglobin from 11.9 to 8.3 mg/dL with a normal coagulation profile. Fluid resuscitation was commenced and 2 units of blood was initially transfused with good haemodynamic response. An urgent CT of the liver with contrast showed active contrast extravasation into a large haematoma just below the right hepatic lobe and abutting the surgical site [Figure 1], with the culprit artery likely to be a segment V segmental artery.

Figure 1

Contrast computed tomography liver showing bleeding from the culprit vessel into the haematoma (arrow)

The patient underwent emergency laparoscopy, haemostasis and hand-assisted evacuation of clots. Three ports were placed through the previous incisions. Diagnostic laparoscopy revealed haemoperitoneum with large amounts of clots preventing good visualisation of the liver and bleeding point [Figure 2]. The decision was made for hand-assisted laparoscopic surgery, and a 7 cm Pfannenstiel incision for the hand-port using Gelport® (Applied Medical, Rancho Santa Margarita, CA, USA) was created. The clots were rapidly evacuated via the hand port and the staple line was overseen laparoscopically with 2 continuous sutures using the V-Loc™ Wound Closure Device (Covidien, Boulder, CO, USA). Thereafter, bipolar forceps was applied to the staple line. Total blood loss was about 2 L and the operation time was 165 min.

Figure 2

Intra-operative laparoscopic image showing the staple line and bleeding point (arrow)

The patient had an uneventful post-operative recovery and was discharged on post-operative day 5 from the date of the liver resection. She received a total of 5 pints of packed cells, 500 ml of fresh frozen plasma and 1 unit of cell-separated platelets throughout her stay. Histology demonstrated that the lesion was a FNH with clear margins.

Although improved peri-operative management and surgical techniques have substantially decreased the incidence of PHH in recent years,[13] it remains an important complication of liver resection, as evidenced by the proposal of a definition and grading by the International Study Group of Liver Surgery in 2011.[3]

Typically, PHH results from three main aetiologies – bleeding from the residual liver surface, which is the also the most common; incomplete intraoperative haemostasis and loosened vascular sutures.[4] Regardless of aetiology, treatment requires early identification. This is important as grade A or mild PHH may only present as a drop in the haemoglobin level with no symptoms.[3] To this end, prompt recognition, timely clotting factor replacement, close observation of vital signs and drain output are crucial.

Open surgery in the form of re-laparotomy has thus far been the mainstay of therapy in PHH, especially when there is haemodynamic compromise or excessive blood loss.[3] It allows for quick identification and direct visualisation of the pathology and enables the application of direct compression over the bleeding site, usually the cut surface of the liver.[5]

Over the last decade, however, there has been growing use of laparoscopy in the emergency setting for both diagnosis and treatment of penetrating abdominal trauma including penetrating liver injury.[2] In our patient who had recent laparoscopic surgery, the choice of emergency laparoscopy for haemostasis was a natural consideration. We decided to use the hand-assisted approach due to the large volume of blood and clots encountered upon entering the abdomen which precluded good visualisation of the bleeding point. This provided better tactile feedback and allowed us to rapidly evacuate blood clots, apply traction to and mobilise the liver and achieve rapid haemostasis through direct finger compression, a benefit also described previously in other studies.[3] Although not totally laparoscopic, these benefits resulted in a shorter operating time, a critical advantage in the emergency scenario, and also spared the patient from a large abdominal wound.

In conclusion, hand-assisted laparoscopic haemostasis is a technically feasible option for the management of PHH. The choice of treatment modality depends on a myriad of factors such as the location of the haemorrhage and post-surgical anatomy, the clinical stability of the patient and the experience and technical expertise of the surgeon.

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Conflicts of interest

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