Justin D Sargent, DO, Steven P Shikiar, MD. Hackensack Meridian Health Palisades
INTRODUCTION: Laparoscopic cholecystectomy has become the standard of care for symptomatic biliary disease due to its minimally invasive nature and low complication rate. Here we present a rare complication of a large ruptured subcapsular liver hematoma and its successful management with laparoscopic control of the hepatic hemorrhage.
CASE REPORT: An 18-year-old female presented with a 9 day history of epigastric and RUQ abdominal pain with daily episodes of emesis. Pain was initially colicky but became constant. Patient was initially evaluated at an outside hospital with abdominopelvic ultrasound, HIDA and EGD. U/S showed acute cholecystitis with gallstones, wall thickening, and pericholecystic fluid. HIDA showed normal filling with decreased ejection fraction. Endoscopy showed a grossly normal stomach and duodenum without signs of gastritis/ulcers. Patient refused cholecystectomy at that time but returned to our hospital and was taken to the operating room for diagnostic laparoscopy.
Intraoperatively her liver and bowel appeared normal. Her gallbladder was grossly distended. A cholecystectomy was performed in the standard fashion without difficulty. Hemostasis of the GB fossa was noted at the end of the case.
On POD#1 she had a vasovagal syncopal episode when standing. HGB dropped from 16 to 10 and a leukocytosis of 39k was noted. Abdominal U/S was performed and showed significant simple RUQ fluid. Three hours later hemoglobin of 7.5 was noted. She remained HD stable. Tachycardia continued to worsen and she was taken to the OR for diagnostic laparoscopy.
Intraoperatively a large subcapsular liver hematoma over the superior surface of the right dome of the liver was noted with a free rupture of Glisson’s capsule at the anterior margin of the liver. 1.4L of hemoperitoneum was evacuated. The liver and abdomen were thoroughly inspected and the majority of the liver capsule was intact. A stable clot was noted under the capsule and left in place. Several small areas of oozing were noted and the free edge of the capsule was packed with surgicel and floseal. No active bleeding was noted at the end of the case. Intraoperatively she received 3u pRBC and FFP.
She had an uneventful post-operative course. After discharge she received a CT scan revealing no sequelae from her surgeries.
DISCUSSION: Exploration of the postoperative patient displaying signs and symptoms of hemorrhage is always indicated. Minimally invasive methods to evaluate and control hemorrhage can be safely used in select cases with a low threshold to convert to open technique.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95747
Program Number: P012
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster