Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):517-522. 10.14701/ahbps.2021.25.4.517.

Rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to control intractable postoperative bleeding from the liver cut surface

• Hwang S
• Na BG
• Kim M
• Won DH

• KMID: 2523056
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.517

Abstract

Various topical hemostatic agents can help induce coagulation at the liver cut surface. However, hemostasis is usually ineffective in controlling bleeding. We present a case of rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to manage intractable postoperative bleeding from the liver cut surface. The case was a 56-year-old male patient with hepatocellular carcinoma in hepatitis B virus-associated cirrhotic liver. The patient was administered warfarin because of graft replacement of the ascending aorta and hemi-arch one year earlier. After warfarin was discontinued, segment VII partial hepatectomy was performed according to standard procedures. However, considerable bleeding occurred during and after hepatectomy. Bleeding from the liver cut surface was controlled over one hour using surface coagulation and topical application of four kinds of hemostatic agents. However, active abdominal bleeding led to reoperation soon after the hepatectomy. During the reoperation, we identified diffuse oozing from the edge of the liver cut surface which was difficult to control. Thus, we performed direct parenchymal injection of fibrin glue at the bleeding points using 12 fibrin glue kits which induced complete hemostasis. Because the patient would undergo anticoagulation again soon after the operation, we also performed hepatorrhaphy. The patient recovered uneventfully after the reoperation. He has been doing well for six months without complications. In conclusion, fibrin glue-infiltrating hemostasis effectively controlled intractable bleeding from the hepatic cut surface in our case. Thus, it can be considered as an optional method for rescue hemostasis.

Keyword

Hemostasis; Fibrin glue; Bleeding; Hepatectomy; Liver cirrhosis

Figure

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  Fig. 1 Preoperative imaging studies showing hepatocellular carcinoma (HCC). (A, B) Dynamic computed tomography images showing a 3.8 cm-sized HCC at the segment VII. (C, D) A contrast magnetic resonance imaging study showing HCC in the background of liver cirrhosis.

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  Fig. 2 Preoperative computed tomography images of aortic dissection. (A) Graft replacement of the ascending aorta and hemi-arch is visible (arrow). (B) Dissection is visible at the abdominal aorta (arrow), which precludes transarterial embolization.

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  Fig. 3 Gross photograph of the resected specimen.

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  Fig. 4 Postoperative computed tomography images taken four hours after initial partial hepatectomy. (A, B) Active bleeding is visible at the edges of the hepatectomy (arrows). (C, D) A large amount of hematoma is visible near active bleeding points (arrows).

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  Fig. 5 Postoperative computed tomography images taken at four days after reoperation. (A, B) There is no evidence of bleeding. The edges of the hepatectomy site appear hypodense (arrows), indicating parenchymal infiltration of fibrin glue. The center of the hepatic parenchymal defect is filled with Surgicel fragments. (C, D) Pledgeted sutures are located at the edges of the hepatectomy (arrows).

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  Fig. 6 Postoperative computed tomography images taken at nine days after reoperation. (A, B) There is no evidence of bleeding. (C, D) The size of hepatic parenchymal defect is reduced without abnormal findings.

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