Hepatothorax: a rare presentation to the trauma surgeon

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A 34‐year‐old woman was brought in post high speed T‐bone collision which resulted in a car rollover and significant intrusion of the vehicle. On presentation, she was alert but haemodynamically unstable. There was clinical suspicion of a right‐sided haemothorax due to reduced oxygen saturations and air entry over her right hemithorax. A chest X‐ray (CXR) showed a dense opacity in the right hemithorax with collapsed lung in the right middle zone (Fig. 1).
An intercostal catheter (ICC) was inserted and computed tomography (CT) scan revealed that the liver was extensively lacerated and was in a high intrathoracic position with the superior part at the level of T4, consistent with a right diaphragmatic rupture (Fig. 2). The ICC appeared to be in close proximity to the hepatothorax, raising the question of further iatrogenic injury to the liver; however, the tip was directed towards the apex and did not penetrate the liver.
The patient underwent emergency exploratory laparotomy. Intraoperative findings confirmed that the liver was in the right hemithorax through a large diaphragmatic defect with coronary ligaments avulsed off the diaphragm. The posterior liver surface was lacerated in multiple areas with bleeding from the parenchyma and bare area of the liver. The liver was reduced back into the abdomen and the large diaphragmatic defect was repaired with 0‐Prolene sutures (Ethicon, Somerville, NJ, USA). Her bleeding injuries were repaired and haemostasis was achieved. The abdomen was packed and the patient transferred to the intensive care unit. She returned for a re‐look laparotomy the following day and the packs were removed. A repeat CT scan 6 days post‐operative showed successful reduction of the hepatothorax with healing liver lacerations (Fig. 3). She was discharged home 2 weeks later.
Acute diaphragmatic ruptures are rare and its reported incidence after blunt trauma ranges from 0.8 to 7%.1 The true incidence however, is unknown as they are underdiagnosed in approximately 7–66% of trauma victims.3 This delayed diagnosis leads to an increase in morbidity and can manifest later as obstruction, strangulation and rupture of abdominal viscera. Thus, prompt diagnosis and treatment is necessary.6
Right‐sided ruptures were reported to be far less common than left‐sided ruptures with an incidence of around 22.5–32%.3 This discrepancy in incidence is thought to be attributed to the cushioning effect of the liver, increased strength of the right hemidiaphragm, under diagnosis of right‐sided ruptures and congenital weakness of the left hemidiaphragm.3
The extent of organ herniation varies depending on the size of the rupture. This can range from a small portion of the liver to the entire liver in addition to other abdominal viscera. Small herniations are typically asymptomatic and diagnosis can be delayed. These asymptomatic herniations are often found 10 years (average) post trauma.2 Large liver herniations require early diagnosis and prompt intervention as congestion due to venous outflow obstruction may cause difficulty in reduction if surgery is delayed.
Signs and symptoms of hepatothorax may vary depending on severity. Patients may present with dyspnoea, upper abdominal pain, cyanosis, cardiac arrhythmias, respiratory distress and hypotension.1 Intrathoracic bowel sounds and unilateral reduction in breath sounds may also be found on examination.7
Preoperative diagnosis is best made by helical CT. CT findings in an acute diaphragmatic rupture include hemidiaphragmatic discontinuity, intrathoracic herniation, collar sign and the dependent viscera sign.2 Other modes of imaging may include upper gastrointestinal studies, plain CXR, ultrasonography and gastroscopy although not as sensitive when compared with CT.6
The management of a hepatothorax secondary to diaphragmatic rupture is highly individualized. A laparotomy is recommended for herniation at the time of injury as it allows identification of potential associated intra‐abdominal injuries.
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