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Emergency right hepatic lobectomy for rupture due to blunt injury
Emergency Right Hepatic Lobectomy for Rupture due to Blunt Injury DONALD M. PEARLMAN, M.D., New York, New York STEPHEN GRAYER, M.Z)., New York, New York
Massive hemorrhage secondary to blunt trauma to the liver may fully challenge the surgeon’s ability and ingenuity. In our mechanized society this problem is becoming increasingly common. Unfortunately, because of the magnitude of the injury, the results have not always been satisfactory. Until the last few years the mortality from blunt trauma to the liver ranged from 45 to 80 per cent [l-4]. In recent reports about 25 per cent of these patients have died [5-r]. Much of this increased survival has been due to improved treatment of shock. However, better understanding of the surgical anatomy of the liver has made possible an aggressive approach to resection of badly traumatized hepatic parenchyma, thereby contributing significantly to the decrease in mortality. This communication reports a case of massive bursting trauma to the liver treated by right hepatic lobectomy.
Case Report The patient (J.P.; No. 05-65-62)) a previously well fifteen year old boy, was brought to Lincoln Hospital Emergency Room thirty minutes after being struck by an automobile. On arrival at the hospital he complained of abdominal pain. Blood pressure was 80/60 mm. Hg and pulse 130 per minute. Physical examination was noncontributory except for a slightly distended and diffusely tender abdomen. Hematocrit was 27 per cent. Abdominal paracentesis yielded a large quantity of dark red unclotted blood. The abdomen was explored through an upper abdominal midline incision. The peritoneal cavity was filled with unclotted blood coming from a ruptured right lobe of the liver. (Fig. 1.) The remainder of the abdominal viscera were intact. Packing of the massive stellate laceration did not From the Department of Surgery, Albert Einstein College of Medicine and Lincoln Hospital, Bronx, New York. Vol.117.
March 1969
even temporarily afford hemostasis. Although 12 units of blood had been given, the patient was still in shock. The incision was carried into the chest through the eighth interspace and the diaphragm was incised. With this improved exposure, the inferior vena cava and right hepatic vein could be exposed. The right hepatic artery, the right hepatic duct, and cystic duct were ligated and divided as was the right branch of the portal vein. The right hepatic vein and several small veins draining the right lobe were secured. An extended right hepatic lobectomy was performed. Hemostasis from the cut edge was achieved mainly by suture ligation of the small vessels in the raw surface. (Fig. 2.) The surgical specimen is shown in Figure 1. Immediately postoperatively the patient did well. On the third postoperative day massive bleeding developed from stress ulcers in the stomach and duodenum. These ulcers were treated by suture, vagotomy, and pyloroplasty. His convalescence was prolonged by a rightLsided subphrenic abscess which was successfully treated with sump drainage and antibiotics. There was laboratory evidence of moderate impairment of liver function shortly after hepatic resection; most indices returned to normal within the next few weeks. (Table I.) A radioactive gold liver scan performed one month after surgery demonstrated a somewhat enlarged left lobe. (Fig. 3.) It appeared that the total mass of the liver was normal. At present the patient is in good health.
Comments Most sharp injuries to the liver can successfully be handled simply by suture [7-81. However,
when
the damage
is due to severe
blunt trauma, the problem becomes more complex. The injury frequently takes the form of a stellate defect with large amounts of necrotic liver substance. Simple suturing of such a lesion or the use of packs for hemostasis may not be effective in controlling bleeding. It will 421
Pearlman
and Grayer
Fig. 1. Resected right lobe of liver. The gallbladder is at the lower right. There is a stellate rupture extending almost through the lobe.
frequently lead to serious postoperative complications such as liver abscess, hemobilia, and secondary hemorrhage [9-l 21. As experience in the management of this problem has increased, it has become apparent that the most effective method of treatment is resection of the involved damaged tissue. If the injury is to the free edge of the lobe, resectional debridement of the area can usually be performed without particular attention to the surgical anatomy of the liver [IO]. This is the procedure actually carried out in most reported “1obectom:es.” However, when the injury is a bursting one of the central portion of the right
lobe, it is necessary to perform a full fledged lobectomy, following the vascular and biliary architecture of the liver lobes. There are relatively few cases in the English literature in which an anatomic right lobectomy has been performed for trauma. The largest such series is that of McClelland and Shires [7’] who report seven right lobectomies in a group of 259 consecutive cases of liver trauma. Their mortality for cases in which resection was involved was 28 per cent. Aronsen et al. [13] report five right hepatic lobectomies for blunt trauma with two deaths. Mays [lh] stresses the point that anatomic lobectomy is the only sure way to control massive hemorrhage from a bursting injury. In his series of blunt trauma to the liver, he reports no deaths secondary to hemorrhage when resection was performed. There have appeared in the literature a scattering of single case reports of right hepatic lobectomy for trauma. Bremer and Dowli [9] report a case of right lobectomy for hemobilia secondary to trauma. Vasko and Scott [1.2] successfully treated a patient with acute renal failure secondary to vena caval compression by an intrahepatic hematoma by resection of the right lobe of the liver. Judd and Moore [15] report an anatomic right lobectomy performed in a ten year old boy who had been struck by an automobile. In some respects their case is similar to the one presented in this paper.
Fig. 2. Appearance of surgical field after right hepaticlobectomy. The medial the liver is being retracted by the suction tip to expose the porta hepatis. 422
segment
of the left lobe of
The American Journal of Surgery
Right Hepatic Lobectomy
TABLE
I
Serial Liver Function Tests after Right Hepatic Lobectomy (April 2, 1957)
References 1.
Date Tests Used Bilirubin (direct/ total) Cephalin flocculation Alkaline phosphatase Cholesterol (total esters)
413
4114
4124
5115
2. 0.15/0.32 0
4.7/10.2
1.4/2.4
0.15/0.65
4+
4+
3+
103 :323,1966. 3.
2.5
11.0
6.4
2.9
135165
75125
. ..
120/60
4.
5.
6.
7.
8.
9.
Fig. 3. Anteroposterior liver scan after right hepatic lobectomy. The X marks the xiphoid process and the C’s the costal margins in the midclavicular fine.
All of the patients who have been reported to survive right hepatic lobectomy have tolerated t,he loss of a large part of the liver and suffered no lasting measurable deficit of hepatic liver function. This clinically observed fact is well supported by experimental work on liver resections in animals [IS]. The surgeon who handles major abdominal trauma should be familiar with the technics of anatomic resection and should not hesitate to proceed with one when confronted with extensive damage to one lobe. Summary A case of right hepatic lobectomy for bursting injury to the liver is presented. The surgical problem is discussed and the literature reviewsd. Vol. 117, March 1%9
CROSTHWAIT, R. W., ALLEN, J. E., MURGA,F., BEALL, A. C., JR., and DEBAKEY, M. E. The surgical management of 640 consecutive liver injuries in civilian practice. Surg. Gynec. & Obst., 114:650, 1962. MIKESKY, W. E., HOWARD,J. M., and DEBAKEY, M. E. Injuries of the liver in 300 consecutive patients. Surg. Gvnec. & Obst.,
10.
11.
12.
13.
14.
15.
16.
SHAFTAN, G. W., GLIEDMAN,M. L., and CAPPELLETTI,R. R. Injuries of the liver: a review of 111 cases. J. Trauma, 3:63,1963. SPARKMAN, R. S. and FOGELMAN, M. J. Wounds of the liver: review of 100 cases. Ann. Surg., 139:690, 1964. BAKER, R. J., TAXMAN, P., and FREEARK, R. J. An assessment of the management of non-penetrating liver injuries. Arch. Surg., 93 :84, 1966. BYRNE, R. V. The surgical repair of major liver injuries. Surg. Gunec. & Obst., 119: 113, 1964. MCCLELLAND,R. N. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161:248, 1965. LONGMIRE, W. P., JR. Hepatic surgery: trauma, tumors and cysts. Ann. Surg., 161: 1, 1965. BREMER, E. H. and DOWLI, A. Traumatic hemobilia : report of primary definitive treatment with right hepatic lobectomy. Am. Surgeon, 32~333, 1966. MAYS, E. T. Management of severe liver trauma. Surg. Gynec. & Obst., 123:661, 1966. VASKO, J. S. and SCOTT, H. W., JR. Acute renal failure from massive intrahepatic hematoma compressing the inferior vena cava: recovery after right hepatic lobectomy. Ann. Surg., 163:144, 1966. WILLIAMS, R. A., GLADDEN,J. C., and NETTLESHIP,M. B. Near fatal procrastination in major hepatic resection. Am. J. Surg., 109 :530, 1965. ARONSEN, K. F., BENGMARK,S., DAHLGREN, S., et al. Liver resection in the treatment of blunt injuries to the liver. Surgery, 63 :236, 1968. MAYS, E. T. Bursting injuries of the liver. A complex surgical challenge. Arch. Surg., 93 :92, 1966. JUDD, D. R. and MOORE,T. C. Right hepatic lobectomy for massive liver trauma: case report. Ann. Surg., 163:149,1966. ATIK, M., GROSSMAN,R., and DEKJZRNIAN, J. Hepatectomy for severe liver injury. AT&. Surg.,
92:636,
1966.
423
Massive hemorrhage secondary to blunt trauma to the liver may fully challenge the surgeon’s ability and ingenuity. In our mechanized society this problem is becoming increasingly common. Unfortunately, because of the magnitude of the injury, the results have not always been satisfactory. Until the last few years the mortality from blunt trauma to the liver ranged from 45 to 80 per cent [l-4]. In recent reports about 25 per cent of these patients have died [5-r]. Much of this increased survival has been due to improved treatment of shock. However, better understanding of the surgical anatomy of the liver has made possible an aggressive approach to resection of badly traumatized hepatic parenchyma, thereby contributing significantly to the decrease in mortality. This communication reports a case of massive bursting trauma to the liver treated by right hepatic lobectomy.
Case Report The patient (J.P.; No. 05-65-62)) a previously well fifteen year old boy, was brought to Lincoln Hospital Emergency Room thirty minutes after being struck by an automobile. On arrival at the hospital he complained of abdominal pain. Blood pressure was 80/60 mm. Hg and pulse 130 per minute. Physical examination was noncontributory except for a slightly distended and diffusely tender abdomen. Hematocrit was 27 per cent. Abdominal paracentesis yielded a large quantity of dark red unclotted blood. The abdomen was explored through an upper abdominal midline incision. The peritoneal cavity was filled with unclotted blood coming from a ruptured right lobe of the liver. (Fig. 1.) The remainder of the abdominal viscera were intact. Packing of the massive stellate laceration did not From the Department of Surgery, Albert Einstein College of Medicine and Lincoln Hospital, Bronx, New York. Vol.117.
March 1969
even temporarily afford hemostasis. Although 12 units of blood had been given, the patient was still in shock. The incision was carried into the chest through the eighth interspace and the diaphragm was incised. With this improved exposure, the inferior vena cava and right hepatic vein could be exposed. The right hepatic artery, the right hepatic duct, and cystic duct were ligated and divided as was the right branch of the portal vein. The right hepatic vein and several small veins draining the right lobe were secured. An extended right hepatic lobectomy was performed. Hemostasis from the cut edge was achieved mainly by suture ligation of the small vessels in the raw surface. (Fig. 2.) The surgical specimen is shown in Figure 1. Immediately postoperatively the patient did well. On the third postoperative day massive bleeding developed from stress ulcers in the stomach and duodenum. These ulcers were treated by suture, vagotomy, and pyloroplasty. His convalescence was prolonged by a rightLsided subphrenic abscess which was successfully treated with sump drainage and antibiotics. There was laboratory evidence of moderate impairment of liver function shortly after hepatic resection; most indices returned to normal within the next few weeks. (Table I.) A radioactive gold liver scan performed one month after surgery demonstrated a somewhat enlarged left lobe. (Fig. 3.) It appeared that the total mass of the liver was normal. At present the patient is in good health.
Comments Most sharp injuries to the liver can successfully be handled simply by suture [7-81. However,
when
the damage
is due to severe
blunt trauma, the problem becomes more complex. The injury frequently takes the form of a stellate defect with large amounts of necrotic liver substance. Simple suturing of such a lesion or the use of packs for hemostasis may not be effective in controlling bleeding. It will 421
Pearlman
and Grayer
Fig. 1. Resected right lobe of liver. The gallbladder is at the lower right. There is a stellate rupture extending almost through the lobe.
frequently lead to serious postoperative complications such as liver abscess, hemobilia, and secondary hemorrhage [9-l 21. As experience in the management of this problem has increased, it has become apparent that the most effective method of treatment is resection of the involved damaged tissue. If the injury is to the free edge of the lobe, resectional debridement of the area can usually be performed without particular attention to the surgical anatomy of the liver [IO]. This is the procedure actually carried out in most reported “1obectom:es.” However, when the injury is a bursting one of the central portion of the right
lobe, it is necessary to perform a full fledged lobectomy, following the vascular and biliary architecture of the liver lobes. There are relatively few cases in the English literature in which an anatomic right lobectomy has been performed for trauma. The largest such series is that of McClelland and Shires [7’] who report seven right lobectomies in a group of 259 consecutive cases of liver trauma. Their mortality for cases in which resection was involved was 28 per cent. Aronsen et al. [13] report five right hepatic lobectomies for blunt trauma with two deaths. Mays [lh] stresses the point that anatomic lobectomy is the only sure way to control massive hemorrhage from a bursting injury. In his series of blunt trauma to the liver, he reports no deaths secondary to hemorrhage when resection was performed. There have appeared in the literature a scattering of single case reports of right hepatic lobectomy for trauma. Bremer and Dowli [9] report a case of right lobectomy for hemobilia secondary to trauma. Vasko and Scott [1.2] successfully treated a patient with acute renal failure secondary to vena caval compression by an intrahepatic hematoma by resection of the right lobe of the liver. Judd and Moore [15] report an anatomic right lobectomy performed in a ten year old boy who had been struck by an automobile. In some respects their case is similar to the one presented in this paper.
Fig. 2. Appearance of surgical field after right hepaticlobectomy. The medial the liver is being retracted by the suction tip to expose the porta hepatis. 422
segment
of the left lobe of
The American Journal of Surgery
Right Hepatic Lobectomy
TABLE
I
Serial Liver Function Tests after Right Hepatic Lobectomy (April 2, 1957)
References 1.
Date Tests Used Bilirubin (direct/ total) Cephalin flocculation Alkaline phosphatase Cholesterol (total esters)
413
4114
4124
5115
2. 0.15/0.32 0
4.7/10.2
1.4/2.4
0.15/0.65
4+
4+
3+
103 :323,1966. 3.
2.5
11.0
6.4
2.9
135165
75125
. ..
120/60
4.
5.
6.
7.
8.
9.
Fig. 3. Anteroposterior liver scan after right hepatic lobectomy. The X marks the xiphoid process and the C’s the costal margins in the midclavicular fine.
All of the patients who have been reported to survive right hepatic lobectomy have tolerated t,he loss of a large part of the liver and suffered no lasting measurable deficit of hepatic liver function. This clinically observed fact is well supported by experimental work on liver resections in animals [IS]. The surgeon who handles major abdominal trauma should be familiar with the technics of anatomic resection and should not hesitate to proceed with one when confronted with extensive damage to one lobe. Summary A case of right hepatic lobectomy for bursting injury to the liver is presented. The surgical problem is discussed and the literature reviewsd. Vol. 117, March 1%9
CROSTHWAIT, R. W., ALLEN, J. E., MURGA,F., BEALL, A. C., JR., and DEBAKEY, M. E. The surgical management of 640 consecutive liver injuries in civilian practice. Surg. Gynec. & Obst., 114:650, 1962. MIKESKY, W. E., HOWARD,J. M., and DEBAKEY, M. E. Injuries of the liver in 300 consecutive patients. Surg. Gvnec. & Obst.,
10.
11.
12.
13.
14.
15.
16.
SHAFTAN, G. W., GLIEDMAN,M. L., and CAPPELLETTI,R. R. Injuries of the liver: a review of 111 cases. J. Trauma, 3:63,1963. SPARKMAN, R. S. and FOGELMAN, M. J. Wounds of the liver: review of 100 cases. Ann. Surg., 139:690, 1964. BAKER, R. J., TAXMAN, P., and FREEARK, R. J. An assessment of the management of non-penetrating liver injuries. Arch. Surg., 93 :84, 1966. BYRNE, R. V. The surgical repair of major liver injuries. Surg. Gunec. & Obst., 119: 113, 1964. MCCLELLAND,R. N. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161:248, 1965. LONGMIRE, W. P., JR. Hepatic surgery: trauma, tumors and cysts. Ann. Surg., 161: 1, 1965. BREMER, E. H. and DOWLI, A. Traumatic hemobilia : report of primary definitive treatment with right hepatic lobectomy. Am. Surgeon, 32~333, 1966. MAYS, E. T. Management of severe liver trauma. Surg. Gynec. & Obst., 123:661, 1966. VASKO, J. S. and SCOTT, H. W., JR. Acute renal failure from massive intrahepatic hematoma compressing the inferior vena cava: recovery after right hepatic lobectomy. Ann. Surg., 163:144, 1966. WILLIAMS, R. A., GLADDEN,J. C., and NETTLESHIP,M. B. Near fatal procrastination in major hepatic resection. Am. J. Surg., 109 :530, 1965. ARONSEN, K. F., BENGMARK,S., DAHLGREN, S., et al. Liver resection in the treatment of blunt injuries to the liver. Surgery, 63 :236, 1968. MAYS, E. T. Bursting injuries of the liver. A complex surgical challenge. Arch. Surg., 93 :92, 1966. JUDD, D. R. and MOORE,T. C. Right hepatic lobectomy for massive liver trauma: case report. Ann. Surg., 163:149,1966. ATIK, M., GROSSMAN,R., and DEKJZRNIAN, J. Hepatectomy for severe liver injury. AT&. Surg.,
92:636,
1966.
423