PMC5422731_01
Intraoperative photographs - case 1. a Upon incision at the abdominal midline, massive bleeding was seen in the abdominal cavity. The patient was positioned with his head to the right. IIIb damage to the right hepatic lobe was discovered at 3 sites (arrowheads): at the superior portion (b), on the surface (c), and at the inferior border (d). If included, the patient's head would be at the top of the photograph.
crg-0011-0190-g01.jpg
PMC5422731_01_crg-0011-0190-g01.jpg
F1
A midline incision was made, and massive bleeding was observed in the abdominal cavity (Fig. 1a). When the field was cleared of blood, we were able to see IIIb damage (Japanese Association for the Surgery of Trauma classification) at 3 sites in the right lobe (Fig. 1b-d).
CT images obtained just after Glissonean pedicle ligation was performed as damage control surgery - case 1. Abdominal CT performed after Glissonean pedicle ligation revealed fully interrupted blood flow in the right hepatic lobe. a Axial image shows absence of blood (arrowhead) in the right lobe, which has been packed with gauze. b Multiplanar reconstruction image more clearly depicts absence of blood (arrowhead) in the right hepatic lobe.
crg-0011-0190-g02.jpg
PMC5422731_01_crg-0011-0190-g02.jpg
F2
Abdominal computed tomography (CT) performed before the patient was admitted to the ICU depicted complete interruption of blood flow in the right hepatic lobe (Fig. 2).
Changes in AST, ALT, and PT% over time in the 3 patients. a, b Black dashed lines are log approximation curves. c Black dashed line is a polynomial approximation curve.
crg-0011-0190-g03.jpg
PMC5422731_03_crg-0011-0190-g03.jpg
F3
BP stabilized. The patient was then admitted to the ICU. Because coagulopathy (PT% 1 day after TAE was 48%) and acute hepatic necrosis occurred (AST and ALT 1 day after TAE were 5,518 and 3,355 IU/L, respectively) (Fig. 3), and signs of abdominal compartment syndrome (increased intravesical pressure and exacerbation of renal function), CT was performed (Fig. 8c), and systematic right hepatectomy as definitive surgery was initiated 24 h after the TAE on the basis of the CT findings of extensive right lobe necrosis.
Intraoperative photographs of the definitive surgery - case 1. a The right hepatic vein (arrowhead) was ligated before transection of the liver parenchyma. b The liver parenchyma (arrowhead) was transected by the clamp-crushing method. c The Glissonean pedicles (anterior branch and posterior branch, [arrowheads]) were transected distal to the point of ligation. d Appearance of the liver upon completion of the right hepatectomy.
crg-0011-0190-g04.jpg
PMC5422731_01_crg-0011-0190-g04.jpg
F4
By appearance, the liver was clearly necrotic, and for this reason the right hepatic vein was ligated before transection of the liver parenchyma (Fig. 4a), which was achieved by the clamp-crushing technique (Fig. 4b). The Glissonean pedicles (anterior and posterior branches), which had been ligated during the initial operation, were transected (Fig. 4c). A photograph of the completed right hepatectomy is shown in Figure 4d, and the resected specimen is shown in Figure 5.
Resected right hepatic lobe - case 1. Photograph obtained shortly after the surgery. The right side of the specimen is the cut side. Large lacerations (arrowheads) are visible at multiple sites.
crg-0011-0190-g05.jpg
PMC5422731_01_crg-0011-0190-g05.jpg
F5
A photograph of the completed right hepatectomy is shown in Figure 4d, and the resected specimen is shown in Figure 5.
PMC5422731_02
CT images obtained at the start of the secondary survey - case 2. a A large IIIb type right hepatic lobe injury (arrowheads) that involved the hilar area was revealed. b A large volume of blood (arrowheads) was detected around the liver and spleen.
crg-0011-0190-g06.jpg
PMC5422731_02_crg-0011-0190-g06.jpg
F6
Because the CT examination had revealed a large IIIb type injury of the right hepatic lobe involving the hilar area (Fig. 6), the Pringle maneuver was performed promptly to interrupt the hepatic inflow. The surgical specimen is shown in Figure 6b.
Photographs obtained during and after the surgery - case 2. a The right hepatic veins (arrowheads) were exposed in the laceration. b Resected right hepatic lobe. Large lacerations (arrowheads) involving the hepatic hilus are apparent.
crg-0011-0190-g07.jpg
PMC5422731_02_crg-0011-0190-g07.jpg
F7
A large laceration was apparent near the base of the posterior Glissonean pedicle (Fig. 7a).
PMC5422731_03
Changes in AST, ALT, and PT% over time in the 3 patients. a, b Black dashed lines are log approximation curves. c Black dashed line is a polynomial approximation curve.
crg-0011-0190-g03.jpg
PMC5422731_03_crg-0011-0190-g03.jpg
F3
BP stabilized. The patient was then admitted to the ICU. Because coagulopathy (PT% 1 day after TAE was 48%) and acute hepatic necrosis occurred (AST and ALT 1 day after TAE were 5,518 and 3,355 IU/L, respectively) (Fig. 3), and signs of abdominal compartment syndrome (increased intravesical pressure and exacerbation of renal function), CT was performed (Fig. 8c), and systematic right hepatectomy as definitive surgery was initiated 24 h after the TAE on the basis of the CT findings of extensive right lobe necrosis.
CT and angiographic images - case 3. a Most of the right hepatic lobe appeared collapsed and thus severely damaged, and extravasation (arrowheads) was seen in the arterial phase in the same area. A large volume of blood (arrowheads) was also seen around the liver and left subphrenic recesses. b Upon angiography, extravasation was seen mainly in the area of the right hepatic artery (arrowhead). TAE was performed until the extravasation disappeared. c CT image obtained 1 day after TAE. Most of the right hepatic lobe had fallen into hemorrhagic necrosis (arrowheads).
crg-0011-0190-g08.jpg
PMC5422731_03_crg-0011-0190-g08.jpg
F8
CT performed after tracheal intubation revealed damage to and collapse of most of the right hepatic lobe, with active extravasation seen in the arterial phase (Fig. 8a).
Intraoperative photographs - case 3. a Four large, complicated lacerations and necrotic changes (arrows) were found in the right hepatic lobe. b Upon completion of the right hepatectomy, forceps were used to grasp the stump of the right hepatic vein (arrowhead).
crg-0011-0190-g09.jpg
PMC5422731_03_crg-0011-0190-g09.jpg
F9
Necrotic changes with a very unpleasant odor were also found (Fig. 9a). After routine cholecystectomy, right hepatectomy was performed by the Glissonean pedicle transection method (Fig. 9b).