Newly diagnosed retroviral infection patient with tumour of the left lobe of the liver . Patient presented with severe pains duestretching of the Gleason capsule and the weight of the tumour . Ultrasound of the liver showed hypoechoic multtinodular tumour involving whole if left lobe if the liver.The largest of the nodules measured 5x5x4 cm3 . The right lobe of the liver was normal in echotexture . Gallbladder was normal
Patient has lost weight due to early satiety from bulk of tumour compressing the stomach. At the time of presentation he wasn’t on antiretroviral therapy. Patient couldn’t cost of histological analysis of tumour . Specimen taken and kept in formalin
Wasted , ill looking but stable, pale, not jaundiced not febrile
Chest was clear, heart sounds normal .
Abdomen looked distended , epigastric mass , tender measuring 15x14cm, no visible veins, no demonstrable ascites.
No periumbilical or virchow nodes present
DRE was unremarkable
Diagnosis :Tumour of left lobe of the liver
Blood counts was normal, liver function and renal function test were normal, clotting time normal
Ultrasound of abdomen:Rt lobe of liver had normal echotexture. Whole of left lobe was filled with nodular masses of tumour. Gallbladder was normal. No intra or extrahepatic biliary dilatation. Head of pancreas normal. no ascites noted
Decision taken to surgically remove left lobe of tumour as debulking surgery to relieve pain and improve patient’s ability to eat.
4 units of fresh blood was secured, iv crystalloids, iv antibiotics were made available for surgery.
Procedure was explained to patient as to goals of surgery and inherent risks. Patient agreed to have surgery done. Informed consent was signed.
Anesthesia : high SAB with infiltration of subcostal skin with 1% xylocaine. Mild sedation was provided with iv ketamine
Incision: Chevron incision
Falciform ligament and right and left coronary ligaments were divided, inferior phrenic veins were secured. Posterior part of liver was packed with abdominal towels in order to mobilise the liver anteriorly.
Gastrohepatic ligament, hepatoduodenal ligaments dissected . Peritoneum overlying porta hepatitis dissected . Left hepatic artery ligated and divided. Left portal vein artery ligated and divided. Left hepatic duct ligated and divided. Left hepatic vein ligated and divided at confluence with inferior vena cava. Middle hepatic vein which was found to drain left lobe was also ligated. having achieved total vascular exclusion of the left lobe, finger fracture dissection carried out to remove left lobe. A segment which was intimately attached to inferior vena cava left undissected
The raw area was packed with abdominal towels. A passive drain was placed in the tumour bed. Abdomen was closed routinely
Total blood volume transfused intraop was 3litres
Total blood volume lost 3litres
Duration of surgery : 6hours
Patient transfused an additional 1unit of blood post op
Post op analgesia was provided by infiltration of wound with marcaine 0.5%
Post operative Outcome
Abdominal pack removed 24hrs later
Drains removed on 5th day
Patient discharged on 8th day on ARVs and oral antibiotics
Patient was seen 3 weeks later with bilious discharge from surgical site. He was managed conservatively with oral metoclopramide 10mg 8hourly . Discharged resolved completely 4 days into admission. Patient discharged home
Submitted by Dr Richard Ametih..specialist, general surgeon
Theatre team members of St Benito Menni Hospital, Adansi Dompoase
Dr R. Ametih…surgeon
Dr Mensah …medical officer
Serwaa Akoto….scrub nurse
Gazaare… scrun nurse
The following nurses too kindly donated blood towards the surgery.