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|Year : 2014 | Volume
| Issue : 3 | Page : 287-289
Brachial plexus injury in live related donor hepatectomy: A chart review
ST Karna, CK Pandey, VK Pandey, A Singh
Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi, India
|Date of Submission||21-Feb-2014|
|Date of Decision||21-Mar-2014|
|Date of Acceptance||02-Jun-2014|
|Date of Web Publication||14-Aug-2014|
Dr. C K Pandey
Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Retrieval of the partial liver graft is a complicated and time-consuming procedure and reported to be associated with brachial plexus injury. We present a case series of brachial plexus injury in live related donor hepatectomy of 95 donors analyzed retrospectively. Seven donors suffered from brachial plexus injuries of varying severity and duration. Out of these, one donor had residual paresis. The reasons could be application of retractors, which may have led to traction and compression above the nerve roots.
Keywords: Brachial plexus injury, live related donor hepatectomy, surgical retractors
|How to cite this article:|
Karna S T, Pandey C K, Pandey V K, Singh A. Brachial plexus injury in live related donor hepatectomy: A chart review. J Postgrad Med 2014;60:287-9
| :: Introduction|| |
Live related donor liver transplantation (LDLT) has increased the availability of viable liver grafts. Live related donor hepatectomy (LDH) is a complicated and time-consuming procedure. The retractors used for proper exposure of surgical area may lead to traction and compression of nerve roots leading to brachial plexus injury (BPI). We present in this paper our experience of BPI in donors who underwent hepatectomy. 
| :: Methodology|| |
IRB approval was obtained with consent waiver and confidentiality of data was maintained.
BPI was considered to be present when there were symptoms of pain, weakness, or paresthesias in the upper limbs, which were not related to a known bone, soft tissue, or vascular injury. 
Selection criteria and study methodology
Perioperative records of 95 LDH done over a period of 3 years were examined. Patients with preexisting neurological deficits and bony, soft tissue, or vascular deformity were excluded. General anesthesia with endotracheal intubation was given in all cases, along with right internal jugular vein and left radial artery cannulation. Patients were placed supine with arms by the side in neutral position (upper arm in adduction, palm facing the thigh with the forearms placed along the side of the body in mid prone position). The Thompson surgical retractor was applied for better surgical exposure [Figure 1]. The total duration of anesthesia and any intraoperative untoward event was noted. Neuromuscular block was reversed and extubation was done in the operation theater in all cases. Presence of postoperative BPI, course during hospital stay, and duration required for recovery were noted in each case.
|Figure 1: Thompson surgical retractor in situ applied for surgical exposure|
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| :: Results|| |
Out of the 95 LDLTs, 7 individuals met the criteria of BPI. Six donors were American Society of Anesthesiologists (ASA) grade I. One donor was ASA grade II with a history of hypothyroidism, but was euthyroid with medications. Five out of these seven donors were overweight with a body mass index (BMI) between 25 and 30 kg/m 2 . The right lobe of liver was retrieved in each of these seven cases. The total duration of anesthesia ranged from 10 to 14 h. No untoward event like hypotension was encountered during the surgery, and no blood product was transfused in any case. The donors complained of numbness, sensory loss, paresthesias, or motor weakness in the right upper limb, which was treated with medical management and physiotherapy, most patients recovered over a period ranging from 2 weeks to 6 months. However, urgent neurological and surgical consultation and decompression fasciotomy were needed in one individual with compartment syndrome in right upper limb leading to neurovascular compromise [Table 1], serial no. 2]. She needed repeated debridement, prolonged medical care, and skin grafting. After medical management and rehabilitation, she has regained motor functions of arm and forearm, though there is still residual paresis in the palmar muscles of right hand after 6 months.
|Table 1: Demographic characteristics and clinical presentation of brachial plexus injury among donors |
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| :: Discussion|| |
Injury to brachial plexus was retrospectively searched in the 95 donors who underwent hepatectomy at our center over 3 years duration. It was detected in seven cases. The predominant symptoms were numbness, followed by pain and motor impairment. In three cases, there was only numbness, whereas significant sensory and motor symptoms were present in the remaining four cases [Table 1]. The recovery period was from 2 weeks to 6 months in six donors. The donor with combined neurovascular injury has not recovered completely even after 6 months of medical and rehabilitative therapy.
The incidence of BPI has been estimated to be 6% in liver donors.  Comorbidities like diabetes, anatomical variations, positioning of the patient, use of automated blood pressure cuffs, surgical retraction, and intraoperative hypotension or vascular compromise in the limb have all been associated with BPI.  The association of nerve injury has been shown with direct pressure, repetitive trauma, stretch, or compression.  The degree of injury may vary with the severity and duration of compression. 
Perioperative stretch or compression of nerves may be because of malpositioning or over abduction of the arm for a prolonged period. ,, Bilateral BPI has been reported after liver transplant in a 35-year-old male recipient. It is suggested that the 90° abduction of the arms may have resulted in excessive stretching of the brachial nerves.  It is also reported that pronation produces the pressure on the ulnar nerve irrespective of arm abduction between 30° and 90°. Thus, a neutral position of the arm, i.e. patients were placed supine with arms by the side in neutral position (upper arm in adduction, palm facing the thigh with the forearms placed along the side of the body in mid prone position), is recommended when it is tucked by the side of the body.  No difference in the incidence of BPI was noted when the arms were at the side or <90° abducted.  In our series, all donors who had BPI were placed with arms at side and hand in neutral position.
There was a unilateral involvement of the right upper limb in all our cases. As all our patients donated the right lobe of the liver, the Thompson retractor was used for better exposure on the right side during the mobilization of liver and parenchymal transaction. This may have attributed to excessive pressure on the right brachial plexus trunks and divisions between the first rib and middle part of the clavicle due to anterior and cephalad movement of the rib cage [Figure 2] by the surgical retractors.  Turning of the head may increase the stretch on the contralateral brachial plexus, but in our series, the head of each patients was kept in neutral position.
|Figure 2: The line diagram of the nerve roots and trunks and their relationship to the clavicle and the first rib. The application of retractor causing upward retraction and compression of structures. This drawing is not anatomically accurate; the nerves and vessels are much closer to each other|
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Compression of the right subclavian vessels at the level of clavicle is the most likely cause of combined neurovascular compromise leading to impending compartment syndrome as occurred in one of our donors [Table 1], serial no. 2]. This went undetected since the left radial pressure was being monitored and pulse oximeter probe had been applied on the left index finger. It would have been prudent to keep the pulse oximeter probe and arterial cannula in separate hands, so that dampening of arterial line or plethysmograph tracing would have detected vascular compromise earlier with immediate corrective measures. In our series, most donors who developed nerve injuries were overweight. This may have led to direct pressure on radial nerve or brachial plexus by the rod used for fixing the Thompson retractor, during lateral tilt which went unnoticed during surgery.
| :: References|| |
|1.||Dulitz MG, De Wolf AM, Wong H, Wray C, Sherwani S, Herborn J, et al. Compression of the brachial plexus during right lobe liver donation as a cause of brachial plexus injury: A case report. Liver Transpl 2005;11:233-5. |
|2.||Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 2010;81:147-55. |
|3.||Ben-David B, Stahl S. Prognosis of intraoperative brachial plexus injury: A review of 22 cases. Br J Anaesth 1997;79:440-5. |
|4.||Kwaan JH, Rappaport I. Postoperative brachial plexus palsy. A study on the mechanism. Arch Surg 1970;101:612-5. |
|5.||Parks BJ. Postoperative peripheral neuropathies. Surgery 1973;74:348-57. |
|6.||Coppieters MW, Van de Velde M, Stappaerts KH. Positioning in anesthesiology. Toward a better understanding of stretch-induced perioperative neuropathies. Anesthesiology 2002;97:75-81. |
|7.||Hida A, Arai T, Nakanishi K, Nagaro T. Bilateral brachial plexus injury after liver transplantation. J Anesth 2008;22:308-11. |
|8.||Prielipp RC, Morell RC, Butterworth J. Ulnar nerve injury and perioperative arm positioning. Anesthesiol Clin North America 2002;20:589-603. |
[Figure 1], [Figure 2]
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