Table Of ContentC R
ASE EPORT
Retraction-Related Liver Lobe Necrosis After
Laparoscopic Gastric Surgery
Anand P. Tamhankar, FRCS Ed, Clive J. Kelty, FRCS, George Jacob, FRCS
ABSTRACT INTRODUCTION
Background: Liver retraction is necessary for optimal Laparoscopic gastric surgery requires adequate visualiza-
exposure during laparoscopic gastric surgery. Though tion of the diaphragmatic hiatus and upper stomach,
transient venous congestion of the retracted lobe of the whichisusuallyconcealedundertheleftlobeoftheliver.
liverisinvariablyseenduringoperations,majorparenchy- Retractionofthislobeisparamountforsatisfactoryaccess
mal injury is rare. We describe a case of Nathanson liver to this region. Such retraction is achieved by different
retractor-induced left lobe liver necrosis and review the techniques, which can vary from simple grasping of the
pertinent literature. parietal peritoneum anterior to the hiatus with a toothed
grasper traversing underneath the left lobe of the liver to
Case Report: A 78-year-old man underwent a laparo-
various flexible or fan-shaped purpose-built retractors.
scopic-assisted total gastrectomy for gastric cancer. A Na-
Another retractor, which is commonly used for this pur-
thansonliverretractorwasusedtoretractalargefattyleft
pose is the Nathanson retractor. The Nathanson retractor
liver lobe. The operation was prolonged due to splenic
is a curved metal blade that lifts the left lobe of the liver
bleeding requiring splenectomy. On the second postop-
and opposes it against the diaphragm, whilst it is exter-
erative day, the patient deteriorated rapidly and devel-
nallyfixedtoasupportingmetalarm.Suchretractioncan
opedmulti-organfailure.Acomputerizedtomogramcon-
cause significant pressure on the liver parenchyma, be-
firmednecrosisoftheleftlobeoftheliverwithgasinthe
cause it is compressed between the metal blade of the
liver parenchyma. The necrotic liver lobe was excised at
retractor and diaphragm, particularly when the patient is
reoperation. The patient died from a postoperative myo-
positioned in the reverse Trendelenburg for a prolonged
cardial infarction.
period.Compression-relatedinjuryandparenchymalfrac-
Discussion: Though minor liver injuries, in the form of turesaremorelikelyiftheliverlobeisenlarged,fatty,and
intraoperative trauma and congestion, are common with fragile.1
laparoscopicliverretraction,majorlacerationsandnecro-
Minor liver injury in the form of venous congestion is
sis are rare. Prolonged surgery and enlarged fatty liver
invariably seen during such laparoscopic procedures, be-
lobe increases the risks of major injury. In our report, we
cause the liver parenchyma is trapped by the retractor.
discussvarioustypesofretractor-relatedliverinjuriesand
Fortunately, such minor pressure-related injuries are usu-
their management and highlight the importance of inter-
allytemporaryandwithoutanymajorclinicalsignificance.
mittent release of retraction during prolonged surgery.
Clinically, they are reflected as a transient elevation of
KeyWords:Laparoscopicsurgery,Liver,Injury,Necrosis. liver enzymes, in particular, aspartate aminotransferase
(AST).Thisbenignphenomenonhasbeendescribedpre-
viously as retraction transaminitis.2 Evidence of such mi-
nor pressure-related retractor injury has also been found
incidentally on serial postoperative CT scans.3
Major lacerations and parenchymal bleeding occur rarely
Department of Upper GI Surgery, Royal Hallamshire Hospital, Sheffield, South andareidentifiedduringprocedures.Likemosttraumatic
Yorkshire,UnitedKingdom(MrTamhankar).
liver injuries, these are usually amenable to conservative
DepartmentofSurgery,DoncasterRoyalInfirmary,Doncaster,SouthYorkshire,
treatment.
UnitedKingdom(Messrs.Kelty,Jacob).
Address correspondence to: Anand P. Tamhankar, 27 Hillcote Close, Sheffield, Delayednecrosisoftheleftlobeoftheliverduetovenous
South Yorkshire, S10 3PT, United Kingdom. Telephone: 07590013636, E-mail:
infarction is a rare complication of laparoscopic liver re-
[email protected]
traction and can have serious implications on the out-
DOI:10.4293/108680811X13022985131651
come. We present a case of such liver necrosis related to
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. Nathansonretractorusedduringaprolongedanddifficult
JSLS(2011)15:117–121 117
Retraction-RelatedLiverLobeNecrosisAfterLaparoscopicGastricSurgery,TamhankarAPetal.
laparoscopic gastrectomy along with a review of the per-
tinentliterature,highlightingthesafetyissueswiththeuse
of laparoscopic liver retraction.
CASE REPORT
A 78-year-old man with gastric cancer underwent a
planned laparoscopic-assisted total gastrectomy. Pre-ex-
isting comorbidites included type II diabetes mellitus,
ischemicheartdisease(previousmyocardialinfarction12
yearsearlier,andoccasionalongoingangina),andbenign
prostatichypertrophy.Hehadalsohadanopencholecys- Figure 1. Temporal changes in serum aspartate transaminase
tectomy several years earlier. (AST).Greaterthan20timeselevationofASTlevelwasreached
at5hoursaftertheoperation(ASTnormallevel(cid:1)5-55IU/L).
Theoperationwasperformedwiththepatientundergen-
eral anesthesia with epidural analgesia. Initial laparo-
scopic findings confirmed no evidence of peritoneal or
occult spread of cancer, but revealed some adhesions
around the cholecystectomy site and dense perisplenic
capsular adhesions. The liver was fatty with a bulky left
lobe. The left lobe of the liver was retracted using the
Nathansonretractor(CookIrelandLtd,Limerick,Ireland),
secured externally through a Murdoch mechanical arm
(Cook Ireland Ltd, Limerick, Ireland). The Nathanson re-
tractor was inserted just below the xiphisternum through
a5-mmtrocarpunctureandplacedundertheleftlobeof
Figure2.Postoperativechangesintheserumlevelsofliverand
the liver, retracting it antero-superiorly to expose the hi-
inflammatory markers. (ALP: alkaline phosphatase; GGT:
atus. With the patient in the reverse Trendelenburg posi-
gammaglutamyltransferase;Bili:totalbilirubin;CRP:C-reactive
tion,laparoscopicmobilizationofthestomachandomen-
protein).
tum was then carried out, and the first part of the
duodenum was divided by using a stapling device and
oversewn. Splenic capsular bleeding was encountered
On the first postoperative day, there were no remarkable
duringmobilizationoftheshortgastrics.Thiscouldnotbe
abdominal findings, and the patient was started on jeju-
controlled with conservative techniques and necessitated
nostomy feed. However, by 48 hours after the operation,
laparoscopic division of the splenic vessels and subse-
thepatienthaddevelopedtachycardiaandfever(temper-
quent splenectomy. A small epigastric transverse incision
ature 38°C). Over the next 6 hours, he rapidly deterio-
was then made to remove the stomach and spleen. A
rated, requiring large doses of inotropes and ventilatory
Roux-en-Yesophagojejunostomywascreatedandafeed-
assistance.
ingjejunostomytubesited.Thetotallaparoscopictimeof
the operation was 3.5 hours. Becausenoobviouscausewasevidentclinically,thesus-
picion of anastomotic dehiscence was raised, and the
The patient was cared for in the intensive care unit post- patientwentontohaveanurgentnoncontrastabdominal
operativelywhereheremainedhypotensiveforthefirst18 computerizedtomogram(CT).TheCTscandidnotshow
hours,requiringincreasinginotropicsupport.By24hours any obvious evidence of anastomotic leak, but demon-
after the operation, his blood pressure stabilized. Serum stratedmassivedestructionintheleftlobeoftheliverwith
AST levels had shot up rapidly when checked 5 hours largeloculationsofintraparenchymalgasaswellasgasin
after the operation and then gradually came down over the portal radicals (Figure 3).
the next 2 days (Figure 1). In contrast, serum levels of
alkaline phosphatase, gamma-glutamyltransferase, total In view of the CT finding of gas-filled liver necrosis and
bilirubin,andC-reactiveproteinwereslowtoriseandfell the presence of septic shock, a decision was made to
only gradually (Figure 2). perform an exploratory laparotomy. At reoperation, the
118 JSLS(2011)15:117–121
Figure3.Sequentialcephalad(a)tocaudad(f)noncontrastCTscanimagesdemonstratingdestructionoftheleftlobeoftheliverwith
freeintraparenchymalgas.Inadditiontoalargeloculusofgas,abranchinglinearpatternofgaswiththeportalradicalsisseenclearly
(e). Also note the absence of spleen, absence of any localized collections, inflammatory stranding in left subhepatic space along the
drainplacedtowardsthehiatus.
leftlobeoftheliverwasnecroticandturgid.Aleftlateral The commonest form of retraction-related injury is sec-
sectionectomy (segments 2,3) was performed. ondary to parenchymal congestion and is evident during
the procedure by the appearance of bluish discolored
The patient remained on inotropic support postopera-
swollen liver tissue trapped lateral to the retractor blade.
tivelyanddiedfromamyocardialinfarction14hourslater.
Usuallythisinjuryisreversible,dependingonthedurationof
retraction and the amount of liver tissue trapped, and may
DISCUSSION
not have any postoperative clinical significance. Usually it
Pertinent literature review performed by using an unre- causestheasymptomaticriseintheserumlevelsofaspartate
stricted PubMed search on the subject confirmed that aminotransferase.2 If the congestion is severe enough to
retraction-related liver injuries are rare. From our experi- cause small parenchymal venous infarctions, it may still re-
enceandreviewoftheavailableliterature,wecanclassify mainasymptomatic,butmaybepickedupasaradiological
liver injuries secondary to mechanical retraction of the abnormalityincidentallyonpostoperativeCTscans.3
liverduringlaparoscopicsurgeryinto3types.Thesearein
the form of minor congestion injury, traumatic parenchy- The second type of retraction injury is uncommon and is
mal rupture, and delayed liver necrosis. aresultofretraction-relatedparenchymalfractureortear.
JSLS(2011)15:117–121 119
Retraction-RelatedLiverLobeNecrosisAfterLaparoscopicGastricSurgery,TamhankarAPetal.
Thesearemorelikelywhentheliveristenseandfragiledue of the liver.13 We picked up 3 other cases involving ne-
tofattyenlargement.Thesecanoccurasadirectinjurybythe crosisoftheleftlobeoftheliverafterlaparoscopicgastric
bladeoftheretractororindirectlyduetoretractionofadja- bypassinanarticle10describingnormalandabnormalCT
centstructures.4-6Mostofsuchparenchymaltraumaisiden- scan findings after laparoscopic gastric bypass surgery.
tified on its occurrence and only causes bleeding, which is This report by Yu et al10 focuses on the CT scan findings
oftenself-limiting.Infrequently,suchdirectretraction-related in consecutive patients who had a CT scan after gastric
parenchymal injury presents postoperatively due to slowly bypass and does not explore the causes of the CT-de-
developingsubcapsularhematoma.7,8 tected abnormalities. It has to be assumed that these 3
cases after laparoscopic bariatric surgery, developing
The third type of injury occurs from substantial paren-
postoperative liver necrosis in the lateral segment of left
chymal necrosis and usually presents late after the ini-
lobe are retractor-related injury. Our case is the first for-
tial procedure. Such injuries are typically identified on
mallyreportedcaseofmassivelivernecrosissecondaryto
a postoperative CT scan and may have variable mor-
Nathanson retractor injury after laparoscopic liver retrac-
phologicalfeatures.9-11Theseinfarctsvaryfromwedge-
tion.
shaped lesions, to rounded lesions or to irregular geo-
graphic lesions. Finding of gas in the area of infarction Our patient had prolonged retraction with a Nathanson
is usually considered a sign of infection. A chronolog- retractorwhileinthereverseTrendelenburgposition,which
ically sequential review of CT scans of 21 liver infarc- has the effect of compression of the left lobe of the liver
tions ranging over a period of 2 days to 53 days by between the diaphragm and the retractor blade against the
Stewart and colleagues11 suggests that liver infarcts pri- pressuresgeneratedbytheweightofthepatient.Thepatient
marily do not have any gas pockets in them, but only developed a remarkable rise in the serum level of AST
acquire them once infection sets in. Such infected in- (Figure1).Thepeaklevelwas(cid:2)20timestheupperlimit
farctions can have gas pockets in the parenchyma, in of normal, which is considered diagnostic for ischemic
well-formed abscess cavities or in the biliary and portal hepatitisintheabsenceofothercausesofhepatitis.14This
radicals in the nondependent part of the involved seg- level of AST is much higher than found in cases of tran-
ment.11 Portal venous gas can also occur secondary to sienttransaminitidis,wherethelevelsremained(cid:3)6times
severe portal pyemia or due to bowel ischemia and the upper limit of normal.2
occasionally due to certain benign conditions.12
Though liver necrosis can be treated conservatively, the
Liver infarcts can be treated conservatively but may get
CT scan confirmed free gas in the liver parenchyma,
complicatedbybileleakandsecondaryinfection.Bothof
whichisusuallyconsideredanindicationforintervention.
thesecomplicationscanbetreatedbypercutaneousdrain-
Because the patient was catastrophically unwell by the
age but surgical intervention may be necessary.11,10,13
time of his CT scan, and we could not exclude any other
Retraction-relatedliverinfarctionhasbeendescribeddur- intraabdominal source of sepsis or anastomotic ischemia,
ingopengastricsurgeryaswell.13Intheirstudy,Kitagawa we had to subject our patient to emergency laparotomy.
andIriyama13describe2casesofleftlobeinfarctionsafter We were able to excise the necrotic liver; however, the
open gastrectomy related to infolding and medial retrac- patient died from a postoperative myocardial infarction.
tion of the left lobe of the liver and compare them with
postoperativehepaticinfarctionsrelatedtodirectinjuryto CONCLUSION
thehepaticartery.Similarly,livernecrosiscanoccurpost-
operativelyafterlivertransplantationorWhipple’ssurgery Massive liver necrosis following laparoscopic liver retrac-
due to vascular insufficiency related to interference near tionisrareandcanbecatastrophic.Insuitablepatients,it
the porta or hepatoduodenal ligament.11 These cases of maybeamenabletoconservativetreatmentorpercutane-
liver necrosis due to operative vascular injury should be ous drainage with others requiring segmental hepatic re-
considered distinctly from retractor-related necrosis. An- section. Prolonged surgery, fatty liver, and the reverse
esthetic agents can also cause massive liver necrosis and Trendelenburg position increase the risk of such injury.
cancomplicatelaparoscopicsurgerybutneedtobeiden- We recommend that the Nathanson liver retractor should
tified as a distinct entity.5 be removed intermittently during prolonged surgery in a
similar situation to re-establish hepatic lobe circulation.
In our review of the published literature for retractor-
related major liver necrosis, we found only 2 confirmed Our article is the first reported case of such massive liver
casesduringopensurgery,andbothinvolvedtheleftlobe necrosisduetosustainedpressureinjuryfromNathanson
120 JSLS(2011)15:117–121
liver retractor used in laparoscopic gastric surgery. Lapa- 7. Pasenau J, Mamazza J, Schlachta CM, Seshadri PA, Poulin
roscopic gastric surgery is being increasingly performed EC.LiverhematomaafterlaparoscopicNissenfundoplication:a
using such liver retractors, and simple steps necessary to case report and review of retraction injuries. Surg Laparosc
EndoscPercutanTech.2000Jun;10(3):178–181.
prevent such injury are often overlooked. This report
increases the awareness of these injuries, which we be- 8. Yoon GH, Dunn MD. Case report: subcapsular hepatic he-
lieveareunderreportedandcanbecatastrophicinnature. matoma: retraction injury during laparoscopic adrenalectomy. J
Endourol.2006Feb;20(2):127–129.
References:
9. Holbert BL, Baron RL, Dodd GD 3rd. Hepatic infarction
1. Fris RJ. Preoperative low energy diet diminishes liver size. caused by arterial insufficiency: spectrum and evolution of CT
ObesSurg.2004Oct;14(9):1165–1170. findings.AJRAmJRoentgenol.1996Apr;166(4):815–820.
2. Morris-Stiff G, Jones R, Mitchell S, Barton K, Hassn A. Re- 10. Yu J, Turner MA, Cho SR, et al. Normal anatomy and com-
traction transaminitis: an inevitable but benign complication of plicationsaftergastricbypasssurgery:helicalCTfindings.Radi-
laparoscopic fundoplication. World J Surg. 2008 Dec;32(12): ology.2004Jun;231(3):753–760.
2650–2654.
11. StewartBG,GervaisDA,O’NeillMJ,BolandGW,HahnPF,
3. Yassa NA, Peters JH. CT of focal hepatic injury due to MuellerPR.Imagingandpercutaneoustreatmentofsecondarily
surgical retractor. AJR Am J Roentgenol. 1996 Mar;166(3):599– infected hepatic infarctions. AJR Am J Roentgenol. 2008 Mar;
602. 190(3):601–607.
4. Hunter JG, Trus TL, Branum GD, Waring JP, Wood WC. A 12. Nelson AL, Millington TM, Sahani D, et al. Hepatic portal
physiologicapproachtolaparoscopicfundoplicationforgastro- venous gas: the ABCs of management. Arch Surg. 2009 Jun;
esophagealrefluxdisease.AnnSurg.1996Jun;223(6):673–685. 144(6):575–581.
5. MedinaLT,VeintimillaR,WilliamsMD,FenoglioME.Lapa- 13. KitagawaT,IriyamaK.Hepaticinfarctionasacomplication
roscopic fundoplication. J Laparoendosc Surg. 1996 Aug;6(4): of gastric cancer surgery: report of four cases. Surg Today.
219–226. 1998;28(5):542–546.
6. FuscoMA,ScottTE,PaluzziMW.Tractioninjurytotheliver 14. Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: clinical
during laparoscopic cholecystectomy. Surg Laparosc Endosc. presentation and pathogenesis. Am J Med. 2000 Aug 1;109(2):
1994Dec;4(6):454–456. 109–113.
JSLS(2011)15:117–121 121
