The hanging manoeuver to complete liver resection for a locally advanced angiosarcoma: A case report

• Primary hepatic angiosarcomas are rare in the Western world.
• At the time of diagnosis, primary hepatic angiosarcomas are often locally advanced.
• Surgeons should be aggressive in the pursuit of complete resections because this is the only treatment modality that has been shown to have a survival advantage.
• In selected cases, the hanging manoeuver may be employed to allow controlled parenchymal transection and minimal bleeding.
• Hepatobiliary surgeons should keep the hanging manoeuver in their armamentarium when performing complex liver resections for locally advanced angiosarcomas.

IntroductionAngiosarcomas arising in the liver are rare tumours in the Western world. We report a case of a locally advanced primary hepatic angiosarcoma and also describe the manoeuvres used to achieve operative resection.Presentation of a caseA 52-year old woman presented with vague right upper quadrant pain. Abdominal imaging revealed a heterogenous tumour in the right liver measuring 15 centimetres in maximal diameter. Although the tumour was deemed to be resectable, there was free fluid in the right paracolic gutter suggestive of rupture.Intra-operatively, the peritoneal cavity was noted to be free of metastatic disease. However, tumour was adherent to the diaphragm precluding traditional mobilization of the liver. Therefore, a modified hanging manoeuvre was performed using a nasogastric tube. This allowed controlled mobilization of the right liver, parenchymal transection and en-bloc resection of the diaphragm with good hemostasis. Histologic examination revealed a primary angiosarcoma with uninvolved margins.DiscussionWhen they occur, primary hepatic angiosarcomas are most often locally advanced. Nevertheless, surgeons should be aggressive in the pursuit of complete resections because this is the only therapeutic modality that has been shown to have a survival advantage.ConclusionHepatobiliary surgeons should keep the hanging manoeuver in their armamentarium when performing complex liver resections for locally advanced angiosarcomas.