Managing Potentially Fatal Bleeding During Laparoscopic Hepatectomy: Intracorporeal Suturing

Abstract

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Laparoscopic liver surgery has evolved substantially along last years and has gained progressive acceptance among liver surgeons. Despite minimally invasive, hepatic resection remains a complex procedure associated with operative complications frequently related to blood loss. Operative hemorrhage is the most common cause to conversion during laparoscopic operations. In instances of massive bleeding conversion may not be the solution since it takes time to open the cavity, place retractors and finally manage the bleeding spot. Another risk during conversion for venous defects is air embolism with non diffusible gases. Methods: Three cases of intraoperative hemorrhage are shown. The first case is a laparoscopic right hepatectomy and bleeding occurred during liver mobilization, when transecting the right coronary ligament an inadvertent lesion occurred to the wall of the right hepatic vein. In this case the surgeon was experienced in both open and laparoscopic liver surgery. Case two depicts a surgeon during the course of his learning curve on liver resection performing a left lateral sectionectomy in which during final phase of liver transection an inadvertent lesion is inflicted to the root of the left hepatic vein. Third case describes another planned right hepatectomy in which a hemostatic clip slips from the inferior vena cava, while dissection is carried out by an experienced conventional liver surgeon, but still climbing the learning curve for minimally invasive operations. Results: All three cases were managed with intracorporeal suturing avoiding conversion. The first two cases did not require blood transfusion and the third patient received two units of packed red blood cells. Conclusion: Potentially fatal hemorrhage can occur at any point of a surgeon's learning curve and at any point of a liver operation. This video shows hemorrhagic events during mobilization, transection and vascular control. Liver surgeons dealing with laparoscopic resections must be trained in both advanced liver and laparoscopic surgery in order to manage operative complications in which the conversion may be riskier than laparoscopic management.