Retraction-Related Liver Lobe Necrosis After Laparoscopic Gastric Surgery

BACKGROUND: Liver retraction is necessary for optimal exposure during laparoscopic gastric surgery. Though transient venous congestion of the retracted lobe of the liver is invariably seen during operations, major parenchymal injury is rare. We describe a case of Nathanson liver retractor-induced left lobe liver necrosis and review the pertinent literature. CASE REPORT: A 78-year-old man underwent a laparoscopic-assisted total gastrectomy for gastric cancer. A Nathanson liver retractor was used to retract a large fatty left liver lobe. The operation was prolonged due to splenic bleeding requiring splenectomy. On the second postoperative day, the patient deteriorated rapidly and developed multi-organ failure. A computerized tomogram confirmed necrosis of the left lobe of the liver with gas in the liver parenchyma. The necrotic liver lobe was excised at reoperation. The patient died from a postoperative myocardial infarction. DISCUSSION: Though minor liver injuries, in the form of intraoperative trauma and congestion, are common with laparoscopic liver retraction, major lacerations and necrosis are rare. Prolonged surgery and enlarged fatty liver lobe increases the risks of major injury. In our report, we discuss various types of retractor-related liver injuries and their management and highlight the importance of intermittent release of retraction during prolonged surgery.