Spontaneous bilateral subcapsular hepatic hematoma following open cholecystectomy and common bile duct exploration: a rare and life-threatening postoperative complication

Hepatic subcapsular hematoma (HSH) is a rare but potentially life-threatening condition characterized by bleeding between the liver parenchyma and Glisson’s capsule. While commonly associated with trauma, pregnancy-related disorders, anticoagulation, or underlying liver disease, postoperative HSH following cholecystectomy is exceedingly uncommon, particularly when bilateral involvement occurs. Early recognition is challenging, yet delayed diagnosis carries a high risk of rupture and mortality. We report the case of a 34-year-old woman who underwent open cholecystectomy with common bile duct exploration for symptomatic cholelithiasis and choledocholithiasis. Despite an initially uneventful postoperative course, she developed sudden massive hemorrhagic drain output on postoperative day two, accompanied by hemodynamic compromise and a precipitous drop in hemoglobin. Imaging revealed a large hepatic subcapsular hematoma. Urgent re-exploration demonstrated extensive bilateral hepatic subcapsular hematomas with diffuse venous oozing and capsular shearing. Damage-control perihepatic packing was performed, followed by staged re-exploration with definitive hemostasis using electrocautery, topical hemostatic agents, plasma sealant, and omentoplasty. The patient recovered successfully and was discharged in stable condition. Postoperative spontaneous bilateral hepatic subcapsular hematoma is an exceptionally rare complication of biliary surgery. Its pathogenesis is likely multifactorial, involving capsular microtears and diffuse venous bleeding rather than discrete arterial injury. Imaging, particularly contrast-enhanced computed tomography, plays a central role in diagnosis. Management must be individualized, with damage-control surgery reserved for unstable patients. This case emphasizes the need for heightened clinical vigilance for hepatic subcapsular hematoma in patients with sudden postoperative hemorrhage following cholecystectomy. Early diagnosis and a structured, stepwise surgical approach are critical to achieving favorable outcomes.