Transesophageal echocardiography uncovers iatrogenic liver injury during minimally invasive mitral valve surgery: case report

Minimally invasive cardiac surgery (MICS) reduces surgical trauma but limits direct visualization of surrounding structures, posing a risk of unrecognized injury. A 65-year-old man with alcoholic cirrhosis underwent mitral valvuloplasty, tricuspid annuloplasty, and Maze procedure via right mini-thoracotomy. During cardiopulmonary bypass (CPB), progressive reservoir volume loss was noted by a perfusionist. However, no collection of blood was evident in the surgical field, and thus, reservoir volume was maintained with volume transfusion. After weaning from CPB, transesophageal echocardiography (TEE) revealed free fluid around the liver. Exploratory laparoscopy confirmed a 1-cm liver laceration likely caused during a trocar insertion. Hemostasis was achieved surgically, and the patient recovered without complications. Iatrogenic liver injury during MICS is rare and may lack intraoperative hemodynamic signs. In this case, timely intraoperative detection of abdominal bleeding using TEE enabled immediate intervention. Routine TEE assessment of intra-abdominal free fluid may help identify similar injuries early and improve patient outcomes.