Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy

Laurence Weinberg; Georgina Hanus; Jonathan Banting; Diana Abu-Ssaydeh; Manfred Spanger; Su Kah Goh; Vijayaragavan Muralidharan

doi:10.1016/j.ijscr.2017.05.005

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy

Int J Surg Case Rep. 2017:36:69-73. doi: 10.1016/j.ijscr.2017.05.005. Epub 2017 May 15.

Authors

Laurence Weinberg¹, Georgina Hanus², Jonathan Banting³, Diana Abu-Ssaydeh⁴, Manfred Spanger⁵, Su Kah Goh⁶, Vijayaragavan Muralidharan⁷

Affiliations

¹ Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia; Department of Surgery, Austin Health, University of Melbourne, 8002, Victoria, Australia. Electronic address: laurence.weinberg@austin.org.au.
² Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia. Electronic address: georgie.hanus@gmail.com.
³ Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia. Electronic address: jkbanting@gmail.com.
⁴ Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia. Electronic address: diana.abussaydeh@gmail.com.
⁵ Department of Radiology, Box Hill Hospital, Box Hill, Victoria, 3128, Australia. Electronic address: spanger@bigpond.net.au.
⁶ The University of Melbourne, Department of Surgery, Austin Health, Australia. Electronic address: sukah84@hotmail.com.
⁷ The University of Melbourne, Department of Surgery, Austin Health, Australia. Electronic address: muv@unimelb.edu.au.

Abstract

Introduction: Major liver resection in a Jehovah's Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah's Witness undergoing left hepatectomy.

Presentation of case: A 65-year-old male Jehovah's Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450mls.

Discussion: Left hepatectomy in a Jehovah's Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases.

Conclusion: Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah's Witness patient.

Keywords: Blood; Embolization; Jehovah’s Witness; Liver resection; Transfusion.