Hepatectomy is a treatment of choice for various forms of liver pathologies such as malignant tumors, benign tumors, intra-hepatic calculi, hydatid disease, necrosis, and abscesses. Despite the livers’ regenerative features, its surgical manipulation comes with significant postoperative morbidity and mortality risks which are 4.09–47.7% and 0.24–9.7%, respectively [1]. Hepatic necrosis secondary to arterial damage is a severe complication of hepatectomies which in most cases are further complicated by gram-negative sepsis. In conjunction these two negative factors carry a mortality rate of approximately 50% [2].

In this report we will discuss the first published case report of post-hepatectomy ischemia post-embolization resulting in hepatic necrosis which was successfully treated with minimal access necrosectomy. This is a hybrid between current advancements in technology and a pool of experience available within a multi-disciplinary team (MDT) of specialist in a well-equipped tertiary hospital.

A 63-year-old female underwent an elective left hepatectomy, cholecystectomy, and Roux-en-Y biliary reconstruction for a type 5 choledochal cyst at another facility (Figure 1: MRCP 20/01/14). Her past medical history includes gastroesophageal reflux, hypothyroidism, tonsillectomy, and tubal ligation. This procedure was indicated by stone formation and recurrent episodes of biliary obstruction from cholelithiasis. Unfortunately, the patient developed a pseudoaneurysm (embolized through interventional radiology) (Figure 2) and subsequent ischemic necrosis of the liver (Figure 3). She was intubated, ventilated, and placed on ionotropic support and intravenous antibiotics. On day 12, she was transferred to Princess Alexandara Hospital’s ICU (Brisbane, Australia) under the Hepatobiliary Team for further management.

She spent 3 out of 9 weeks in ICU. During her admission, she had a percutaneous pigtail drain placed into a necrotic collection of the right hemiliver (Figure 4). When her liver enzymes and abdominal pain improved she was discharged with the pigtail in situ on week 9. She later underwent an elective minimal access endoscopic debridement of right hepatic necrosis 77 days after the initial operation.

Upon extensive literature search, the authors have found that this minimal access endoscopic debridement of chronic hepatic necrosis is the first ever reported. There has been a reported case study by Talar T. in 2007 where a laparoscopic debridement of hepatic necrosis was carried out, but not through this report specific minimal laparoscopic methods [3]. This procedure was done under General Anesthesia with an intra-op single dose of intravenous antibiotics. Access was gained via the pre-existing 14 Fr pigtail drain with the help of a guidewire, Nephromax (Flexima Locking Loop Nephrostomy Catheter—14 Fr M0064101430/Re-Entry Malecot Nephrostomy Catheter—14 Fr Catheter, 6 Fr) and 30 Fr sheath under radiological guidance. The necrosectomy was carried out successfully and a 19 blakes drain was sutured in place with a coloplast bag. This was a one-off procedure and repeats were not required. Operating time was 1 hour 16 minute and the patient was kept in overnight and discharged the next day.

The patient has recovered from her hepatic necrosis and now has normal ducts in segments 5 and 8 and abnormal dilated ducts in residual segments 6, 7, and 1 (Figure 5). She has experienced recurrent Klebsiella Cholangitis occasionally which has been treated conservatively with antibiotics as per a MDT meeting.

Liver resection is performed as treatment options for various disorders. Among several contributory factors technological advancements, surgical experience, and multi-disciplinary input had significantly improved postoperative outcomes following hepatectomies [4]. Hepatic necrosis compounded with sepsis is one of the more severe complications of a hepatectomy.

In this case study, the likely cause of hepatic necrosis is arterial injury leading to thrombosis during the initial elective left hepatectomy. A “step-up” approach was utilized where initial treatment was primarily conservative. This approach is similar to the relatively recent adaptation of minimal access pancreatic necrosectomies. The PANTER study performed in the Netherlands showed that there was a significant decrease in major complications using a “step-up” approach compared to open necrosectomies in the management of pancreatic necrosis [5].

Minimally invasive approaches have several proven advantages such as to lower morbidity and mortality [6], keeping an infection compartmentalized and reducing systemic inflammatory and septic response. Reduced pain, operation time, and admission duration are more advantages of a minimally invasive approach [6].

The patient in this case was a suitable candidate for the use of endoscopic instruments for minimal access hepatic necrosectomy as the procedure was performed after a 3-month delay similar to the laproscopic approach mentioned by Talar et al. in 2007. This would have resulted in better demarcated borders between necrotic and healthy hepatic cells as well as less intra-operative bleeding.

Infected hepatic necrosis is a severe complication secondary to hepatectomies. A step up approach with minimal access hepatic necrosectomy via “endoscopic” means can result in significantly less morbidity and mortality for patients. We advocate that such an approach be carried out in a Tertiary Hospital with the availability of a Multi-disciplinary Team, involving Hepatobiliary Surgeons, Intensive Care Physicians, Interventional Radiologists, and others.