Figure 1
Abdominal ultrasonography
Inhomogeneous hypoechoic collection surrounding the right lobe of the liver. The lower portion of the collection shows a multilayered appearance (left panel).
Conservative treatment of hepatic subcapsular haematoma following laparoscopic cholecystectomy
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsSergio Savastano, Alessandra Costantini, Davide Dal Borgo, Stefano Trupiani, Leonardo Giarraputo
Connected authors
74 years, male
Clinical History
The patient presented pain in the right upper abdominal quadrant and fever (38 °C). He had undergone laparoscopic cholecystectomy for cholelithiasis three weeks before in another hospital. Laboratory tests demonstrated decreased haemoglobin (9.4 mg/L); white cell count was normal. Fever relieved with broad-spectrum intravenous antibiotics; conservative treatment was uneventful.
Imaging Findings
Ultrasound showed a hypoechoic inhomogeneous collection surrounding the right lobe of the liver (Fig. 1).
Contrast-enhanced CT demonstrated a large intrahepatic subcapsular collection, partially hyperattenuating; a small gas bubble was also recognized (Fig. 2). No active extravasation of contrast medium was detectable.
The patient was treated conservatively in agreement with the surgeons and monitored with serial US examinations. Contrast-enhanced CT performed one month later showed decrease in size of the intrahepatic subcapsular collection; no gas bubble was evident at that time (Fig. 3). Resolution of the collection was demonstrated two months after surgery (not shown).
Contrast-enhanced CT demonstrated a large intrahepatic subcapsular collection, partially hyperattenuating; a small gas bubble was also recognized (Fig. 2). No active extravasation of contrast medium was detectable.
The patient was treated conservatively in agreement with the surgeons and monitored with serial US examinations. Contrast-enhanced CT performed one month later showed decrease in size of the intrahepatic subcapsular collection; no gas bubble was evident at that time (Fig. 3). Resolution of the collection was demonstrated two months after surgery (not shown).
Discussion
Hepatic subcapsular haematoma accounts for 0.1-0.86% of complications of laparoscopic cholecystectomy [1–3]. Aetiology of this potentially life-threatening complication comprises the following causes [1, 4–6]:
1. excessive bending of the liver capsule during traction of the gallbladder
2. direct trocar lesion
3. hepatic injury during dissection of the gallbladder
4. bleeding from a pre-operatively unrecognized haemangioma
5. sudden drop of intra-abdominal pressure at the end of the operation
Administration of anticoagulants or nonsteroidal anti-inflammatory drugs, such as ketorolac and diclofenac sodium for analgesia in the perioperative period, increases the risk of bleeding [7, 8]. Intrahepatic subcapsular haematoma can spontaneously resolve; intraperitoneal rupture and infection are possible complication [8, 9].
Diagnosis of intrahepatic subcapsular haematoma is easy to achieve with CT, which can also demonstrate an active bleeding [8]. Evidence of gas bubbles must alert the radiologist to the possibility of a bacterial superinfection [8]. However, as in the present case, a gas bubble may be not pathognomonic of an infection, and therefore conservative treatment with an antibiotic coverage may be attempted when the infection can be clinically excluded. Nonetheless percutaneous drainage should be performed whenever a bacterial contamination is evident or suspected [8, 9].
Since an intrahepatic subcapsular haematoma is a rare complication of a laparoscopic cholecystectomy, it is impossible to propose therapeutic guidelines, and therefore treatment should be chosen on a case by case basis. Emergency laparotomy is obviously indicated in haemodynamically unstable patients [6, 7], whereas transcatheter arterial embolization should be performed when active bleeding is demonstrated in contrast-enhanced CT [8]. Percutaneous US-guided drainage is an effective and safe treatment, alternative to surgery, in stable patients with a delayed intrahepatic subcapsular haematoma [11]. However, as an intrahepatic subcapsular haematoma can spontaneously heal [3, 5], close monitoring of the patient with US and CT can be proposed until complete reabsorption of the haematoma can be demonstrated.
1. excessive bending of the liver capsule during traction of the gallbladder
2. direct trocar lesion
3. hepatic injury during dissection of the gallbladder
4. bleeding from a pre-operatively unrecognized haemangioma
5. sudden drop of intra-abdominal pressure at the end of the operation
Administration of anticoagulants or nonsteroidal anti-inflammatory drugs, such as ketorolac and diclofenac sodium for analgesia in the perioperative period, increases the risk of bleeding [7, 8]. Intrahepatic subcapsular haematoma can spontaneously resolve; intraperitoneal rupture and infection are possible complication [8, 9].
Diagnosis of intrahepatic subcapsular haematoma is easy to achieve with CT, which can also demonstrate an active bleeding [8]. Evidence of gas bubbles must alert the radiologist to the possibility of a bacterial superinfection [8]. However, as in the present case, a gas bubble may be not pathognomonic of an infection, and therefore conservative treatment with an antibiotic coverage may be attempted when the infection can be clinically excluded. Nonetheless percutaneous drainage should be performed whenever a bacterial contamination is evident or suspected [8, 9].
Since an intrahepatic subcapsular haematoma is a rare complication of a laparoscopic cholecystectomy, it is impossible to propose therapeutic guidelines, and therefore treatment should be chosen on a case by case basis. Emergency laparotomy is obviously indicated in haemodynamically unstable patients [6, 7], whereas transcatheter arterial embolization should be performed when active bleeding is demonstrated in contrast-enhanced CT [8]. Percutaneous US-guided drainage is an effective and safe treatment, alternative to surgery, in stable patients with a delayed intrahepatic subcapsular haematoma [11]. However, as an intrahepatic subcapsular haematoma can spontaneously heal [3, 5], close monitoring of the patient with US and CT can be proposed until complete reabsorption of the haematoma can be demonstrated.
Differential Diagnosis List
Subcapsular liver haematoma complicating laparoscopic cholecystectomy
Hepatic subcapsular abscess
Perihepatic abscess
Final Diagnosis
Subcapsular liver haematoma complicating laparoscopic cholecystectomy
References
[1] Deziel DJ, Millikan KW, Economou SG, et al. (1993) Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 165:9–14 (PMID: 8418705)
[2] Malik A, Laghari A, Mallah Q, et al. (2008) Extra-biliary complications during laparoscopic cholecystectomy: How serious is the problem?. Minim Access Surg 4:5-8 (PMID: 19547669)
[3] Triantafyllidis I, Nikoloudis N, Sapidis N, et al. (2009) Complications of laparoscopic cholecystectomy: our experience in a district general hospital. Surg Laparosc Endosc Percutan Tech 9:449–458 (PMID: 20027087)
[4] Pietra N, Sarli L, Costi R, Violi V (1998) Intrahepatic subcapsular hematoma. A rare postoperative complication of laparoscopic cholecystectomy. Surg Laparosc Endosc 8:304–307 (PMID: 9703607)
[5] Antsaklis G, Karanikas I, TE S, et al. (2009) Subcapsular hematoma of the liver: a rare complication of the laparoscopic cholecystectomy. Minerva Chir 64:322–323 (PMID: 19536061)
[6] Shibuya K, Midorikawa Y, Mushiake H, et al. ( (2010) Ruptured hepatic subcapsular hematoma following laparoscopic cholecystectomy: Report of a case. Biosci Trends 4:355–358 (PMID: 21248436)
[7] Minaya Bravo AM, González González E, Ortíz Aguilar M, Larrañaga Barrera E (2010) Two rare cases of intrahepatic subcapsular hematoma after laparoscopic cholecystectomy. Indian J Surg 72:481–484 (PMID: 22131659)
[8] De Castro SMM, Reekers J A, Dwars BJ (2012) Delayed intrahepatic subcapsular hematoma after laparoscopic cholecystectomy. Clin Imaging 36:629–631 (PMID: 22920379)
[9] Okumus M, Ezberci F, Kuzhan N, et al. (2011) A Rare Cause of Dyspnea in a Patient Presenting to the Emergency Department: A Case Report and Review of the Literature of Laparoscopic. J Clin Med Res 3:262–264 (PMID: 22383915)
[10] Brown V, Martin J, Magee D (2015) A rare case of subcapsular liver haematoma following laparoscopic cholecystectomy. BMJ Case Rep bcr2015209800 (PMID: 26113588)
Case information
| URL: | https://www.eurorad.org/case/13037 |
| DOI: | 10.1594/EURORAD/CASE.13037 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Emergency CT
Non-enhanced scan: large intrahepatic subcapsular collection with hyperattenuating component, consistent with haematoma.
Contrast-enhanced scan (portal phase): no extravasation of contrast medium.
Contrast-enhanced scan (portal phase): a gas bubble is evident on a cephalad scan.
Contrast-enhanced scan: sagittal reformation.
Abdominal ultrasonography
Inhomogeneous hypoechoic collection surrounding the right lobe of the liver. The lower portion of the collection shows a multilayered appearance (left panel).
Ospedale San Bortolo, Vicenza, Italy
Ospedale San Bortolo, Vicenza, Italy
Emergency CT
Non-enhanced scan: large intrahepatic subcapsular collection with hyperattenuating component, consistent with haematoma.
Ospedale San Bortolo, Vicenza, Italy
Ospedale San Bortolo, Vicenza, Italy
Contrast-enhanced scan (portal phase): no extravasation of contrast medium.
Ospedale San Bortolo, Vicenza, Italy
Ospedale San Bortolo, Vicenza, Italy
Contrast-enhanced scan (portal phase): a gas bubble is evident on a cephalad scan.
Ospedale San Bortolo, Vicenza, Italy
Ospedale San Bortolo, Vicenza, Italy
Contrast-enhanced scan: sagittal reformation.
Ospedale San Bortolo, Vicenza, Italy
Ospedale San Bortolo, Vicenza, Italy
