Staple-line disruption of a short left-middle hepatic venous common trunk causing right atrial injury during extended left hepatectomy: A case report

Injury to the inferior vena cava or the major hepatic veins is a life-threatening complication that can occur during hepatectomy. To prevent catastrophic outcomes, careful preoperative assessment of the venous anatomy, the selection of appropriate transection techniques, and advance coordination with cardiovascular surgical teams are essential. A 67-year-old male underwent an extended left hepatectomy with caudate lobectomy for intrahepatic cholangiocarcinoma that had invaded the roots of the left and middle hepatic veins. The common trunk of these veins was divided using a vascular stapler, and pulsatile bleeding developed from the staple-line approximately 4 minutes after transection. Despite immediate attempts at hemostasis, the staple-line disruption progressed; the laceration was ultimately found to extend from the hepatic venous confluence into the right atrium, resulting in uncontrollable hemorrhage. Cardiopulmonary bypass was established immediately, and complete hemostasis was achieved with primary repair. The patient recovered without major complications and remains alive 1 year after surgery. An extremely short left-middle hepatic venous common trunk located in close proximity to the right atrium may represent a technically challenging configuration for hepatic vein transection. Recognizing such anatomy preoperatively may encourage surgeons to consider alternative transection techniques and to plan vascular control strategies in advance for unexpected major venous bleeding.