Simon Wabitsch, PD Dr. med. Timm Denecke, PD Dr. med. Dominik Geisel, Dr. med. Ann-Christin von Brünneck, Dr. med. Andreas Andreou, Prof. Dr. med. Matthias Biebl, Prof. Dr. med. Johann Pratschke, PD Dr. med. Moritz Schmelzle
Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany (all authors).
Introduction: Spontaneous rupture of liver tumors, such as hepatocellular adenoma (HCA) and carcinoma (HCC), is rare, but may be life threatening, as unspecific symptoms can be misleading. Immediate diagnosis, angiographic intervention and surgery is needed to stop the bleeding.
Case Description: We present a case of a ruptured HCA, which was addressed by a 2-step interventional and laparoscopic approach. A female 53-year-old patient was admitted to the hospital with unspecific epigastric pain for the past 3 days. Acute coronary syndrome was initially suggested because of a history of hypertension, but could be ruled out in further investigation. Ultrasonography and a subsequent contrast-enhanced computed tomographic (CT) scan of the abdomen showed a massive deterioration of the left-lateral section, with active bleeding from a ruptured liver tumor and free-floating blood in the peritoneal cavity. Successful emergency angiographic embolization was accomplished with gelatin foam powder (Gelita-Spon, Gelita Medical, Germany) in the hemodynamically stable patient. Subsequent magnetic imaging (MRI) with the hepatospecific contrast agent gadoxetate sodium (Gd-EOB or Primovist/Eovist; Bayer, Leverkusen, Germany) revealed the most likely diagnosis of an HCA, which had been ruptured. Two additional adenomas 3 cm in diameter in liver segments 4 and 6 were diagnosed without the need for further treatment. We performed a single-incision laparoscopy to evacuate the hematoma and to address the ruptured liver tumor. Anatomic left lateral sectionectomy was performed with a harmonic scalpel and a vascular stapler. The resected liver lobe was removed through the umbilical single-port incision. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.
Discussion: This case emphasizes the importance of interdisciplinary management of ruptured liver tumors and highlights advantages of single-incision laparoscopy over laparotomy in the management of emergency liver resection.
Key Words: Angiographic intervention, Emergency laparoscopic liver resection, Ruptured liver adenoma.