Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery

a Department of Anaesthesia, Resuscitation and Intensive Care, General University Hospital, 1st School of Medicine, Charles University, U Nemocnice 2, 128 00, Prague 2, Czech Republic b Department of Cardiovascular Surgery, General University Hospital, 1st School of Medicine, Charles University, Prague, Czech Republic c 2nd Department of Internal Medicine, General University Hospital, 1st School of Medicine, Charles University, Prague, Czech Republic *Corresponding author. Tel.: +420-224962733; fax: +420-224922695. E-mail address : jan.kunstyr{at}post.cz (J. Kunstyr). We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear. Key Words: Hemoperitoneum; Cardiac surgical procedures; Intra-operative complication