Interact CardioVasc Thorac Surg 2008;7:435-436. doi:10.1510/icvts.2007.173757
© 2008 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery
Jan Kunstyra,*,
Jan Tosovskyb,
Josef Korinekc and
Martin Striteskya
a Department of Anaesthesia, Resuscitation and Intensive Care, General University Hospital, 1st School of Medicine, Charles University, U Nemocnice 2, 128 00, Prague 2, Czech Republic
b Department of Cardiovascular Surgery, General University Hospital, 1st School of Medicine, Charles University, Prague, Czech Republic
c 2nd Department of Internal Medicine, General University Hospital, 1st School of Medicine, Charles University, Prague, Czech Republic
Received 18 December 2007;
received in revised form 24 January 2008;
accepted 25 January 2008
*Corresponding author. Tel.: +420-224962733; fax: +420-224922695.
E-mail address: jan.kunstyr{at}post.cz (J. Kunstyr).
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Abstract
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We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.
Key Words: Hemoperitoneum; Cardiac surgical procedures; Intra-operative complication
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1. Introduction
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Intra-abdominal complications during or after cardiopulmonary bypass (CPB) are rare events and do have high mortality rates [1–7]. Hemoperitoneum developing early during cardiac surgery is a very rare, yet a life-threatening complication [1, 2]. We report an unusual presentation of intra-peritoneal bleeding secondary to hepatic tear and discuss the possible causes and contributing factors to such a complication.
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2. Case report
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A 62-year-old female (65.5 kg, 159 cm) with remote history of mitral commissurotomy (1970) and aortic and mitral valve replacement (1990) with mechanical prostheses was elected to redo procedure on aortic valve due to severe paravalvular leak. A comprehensive preoperative assessment was unremarkable except for venous engorgement of the liver on ultrasound, however, there was no clinical or laboratory evidence of hepatic congestion.
Intra-operatively, a routine median resternotomy was performed using an oscillating saw. The pre-bypass period was prolonged secondary to the presence of extensive pericardial adhesions requiring dissection. Hypovolemia was noted and an adequate volume of colloids and crystalloids were administered. Despite the lack of obvious signs of overt bleeding, the hematocrit dropped from 38% to 28%. The surgery proceeded with full heparinization, followed by CPB with administration of 1750 ml of priming solution. Subsequently, 1000 ml of blood was suctioned from the right pleural cavity. A small pleural defect was identified after the heart emptied on CPB circuit. This was thought to be the cause of the right hemothorax, and thus the hematocrit drop. After administration of 600 ml of crystalloid cardioplegia, the hematocrit during the CPB continued to drop significantly to as low as 12%. Small amounts of blood were continually suctioned from the right pleural cavity and were considered to be responsible for the further drop in the hematocrit, along with hemodilution. Packed red blood cells, colloids and small dose of norepinephrine (up to 0.05 µg·kg-1·min-1) were administered to maintain a mean arterial blood pressure of 50–60 mmHg. Hematocrit continued to be low (18%). The surgeon proceeded with replacement of the aortic valve prosthesis and tricuspid valvuloplasty.
During the reperfusion period, bluish discoloration of the right hemidiaphragm was noted, in addition to marked distension of the upper abdomen. Immediate laparotomy was performed and about 2500 ml of blood and approximately 500 ml of blood clots were suctioned from the peritoneal cavity. A linear tear (15 mm), along the midline on the superior aspect of the right hepatic lobe, was found and repaired. No diaphragmatic breach was identified. The patient was successfully weaned off the CPB. Estimated blood loss in the operating room was 3500 ml. In addition to the total of 6200 ml of blood products, the patient received 1000 U of antithrombin III and 2 g of fibrinogen. The patient was discharged home after 22 days stay in the critical care unit and was doing well at six months follow-up visit.
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3. Discussion
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Reports of liver bleeding accompanying cardiac surgery are rather anecdotal and scarce, related only once to direct trauma caused by palpation of the liver, chest tube insertion, or an extremely firm sternal exostosis [1]. Spontaneous hepatic rupture in cardiac surgery with hemoperitoneum has been described only in a prosthetic aortic valve replacement due to endocarditis [8].
In this case, the presence of blood in the right pleural cavity and bleeding from the adhesions offered a plausible explanation for the initial drop of the hematocrit. With no evidence of diaphragmatic injury, iatrogenic liver trauma was not suspected and the aforementioned causes of intraperitoneal bleeding were not conceivable. However, the progressive fall in the hematocrit, hardly explainable by hemodilution, should have prompted a search for another source of bleeding. The actual explanation for this discrepancy became evident after the signs of hemoperitoneum developed.
We hypothesize that the oscillating saw used for sternotomy was the actual cause of the hepatic tear. The extensive scarring as a sequel of the previous sternotomy and xiphoidectomy resulted in an adherent band between the inner surface of the sternum and the surrounding tissues. This band represented the only barrier protecting the underlying liver from the vibratory forces of the saw. The linearity, direction and localization of the hepatic tear support this hypothesis. The hepatic venous engorgement as a consequence of chronic tricuspid regurgitation was likely contributing to liver fragility. We further speculate that minute diaphragmatic defects could cause seepage of blood from the peritoneal to the pleural cavity [9] and thus contribute to continuous presence of blood in the pleural cavity.
After this experience, we have implemented lifting the sternum in its lower part with Backhaus towel clamps to increase the distance between saw and liver, thus protecting the liver from possible indirect trauma and preventing a similar complication during resternotomy.
In conclusion, identification of a relatively minor source of bleeding within the operative field might be misleading as to the explanation of drop in the hematocrit during cardiac surgery. Even though the association between cardiac surgery and intra-abdominal bleeding might not be obvious at first sight, our case report documents that the abdominal cavity needs to be considered as a possible source of bleeding if other causes are excluded. Intraperitoneal bleeding due to hepatic tear should be taken into consideration in the differential diagnosis of unexplained blood loss during cardiac surgery involving the use of an oscillating saw, despite an intact diaphragm. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.
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References
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Abstract
1. Introduction