LAUSR

An otherwise healthy and active, 90-year-old male was urgently referred from a community hospital to our tertiary care hepato-pancreato-biliary center with a 9-h history of acute onset epigastric pain and nausea. Upon arrival, he was noted to have peritonitis localized to the epigastrium and right upper quadrant, with an underlying semi-mobile, tender mass. His laboratory investigations identified an elevated white blood cell count of 19.5 (×10 × 9/L), alanine transaminase of 1045 (U/L) and international normalized ratio of 1.4. Computed tomography of his torso confirmed a congenital variant of the left liver that was highlighted by a thin bridge of parenchyma connecting the left and right lobes (i.e., with a completely non-fixed left lobe). The left hepatic lobe was torted and displaced into the right lateral abdomen with an associated swirling/ twisting of the inflow vasculature, focal narrowing of the left hepatic artery, and occlusion of the left hepatic vein (Fig. 1). Immediate operative exploration through a small upper midline incision confirmed a complete torsion of the left hepatic lobe with associated ischemia and venous congestion (Figs. 2 and 3). A left hepatectomy was performed with a single firing of a linear vascular stapler without detorsion of the liver (i.e., to prevent a systemic flush of contents from the ischemic liver). Total operative time was 28 min. Microscopic examination of the specimen confirmed hemorrhagic necrosis consistent with vascular compromise. The patient was discharged home in good condition on postoperative day five. Torsion of the left hepatic lobe has been previously described in patients with accessory left lobes. 2 Interestingly, only one other case has been published outlining torsion of an anatomic left lobe in a 19-yearold female. This example was complicated by a late diagnosis (3 days), multiple capsular ruptures, and an absence of right lateral displacement/movement of the torted left lobe (i.e., the patient still possessed multiple left liver attachments). The paucity of reports describing this