eISSN: 2508-8033 pISSN: 2508-5298
How to do it in Trauma
Right Hemihepatectomy after Damage control Surgery for High-grade Hepatic Injury with Diaphragm Rupture Dong Hun Kim Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
Liver resection is believed to play a minimal role in the management of hepatic injury because of the high morbidity and mortality associated with it. However, the staged management of high-grade hepatic injuries with anatomic or nonanatomic resection can be accomplished with low mortality and morbidity after a successful damage control surgery. Here, we describe a case of successful major liver resection performed in stages after damage control surgery with effective perihepatic packing in a 40-year-old male with high-grade hepatic injury and diaphragm rupture following crushing thoracoabdominal trauma. (Trauma Image Proced 2018(1):25-27) Key Words: Hepatectomy; Blunt injury; Damage control surgery
CASE
operation time of 84 min (Video 1.). After the damage control surgery, a lethal triad with a pH of 7.26, lactate
A 40-year-old male was admitted with penetrating and
level of 4.3 mmol/L, international normalized ratio of
blunt injury to his right thoracoabdominal area caused
2.40, and a temperature of 35.1°C occurred and was
by a crushing accident at his workplace (Fig. 1.). Upon
corrected after resuscitation of transfusion and warming
admission, he was alert with a blood pressure of 135/81
in the intensive care unit (ICU). Definitive surgery,
mm Hg, pulse rate of 109 beats/min, respiratory rate of
including
40/min, and hemoglobin level of 8.5 g/dL. Physical
abdominal closure, was performed 12 h after the first
examination revealed peritoneal irritation signs on the
operation (Video 2.). The patient was discharged without
whole abdomen. A focused assessment with sonography
any complications 20 days after the definitive surgery.
right
hemihepatectomy
and
definitive
for trauma revealed large amounts of intra-abdominal fluid collection in the Morison pouch and splenorenal
DISCUSSION
recess. Computed tomography performed in response to resuscitation demonstrated a right hepatic injury and a
Patients with high-grade hepatic injury are susceptible
right diaphragm rupture with herniation of the colon
to the lethal triad of coagulopathy, acidosis, and
(Fig. 2.). He underwent emergency laparotomy, including
hypothermia. These patients benefit from damage control
primary repair of the right diaphragm, perihepatic
resuscitation and physiological restoration in the ICU.
packing, and temporary abdominal closure, with an
Perihepatic packing as a damage control surgery can be
Received: April 18, 2018 Revised: May 14, 2018 Accepted: May 16, 2018 Correspondence to: Dong Hun Kim, Department of Trauma Surgery, Trauma Center, Dankook University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Republic of Korea Tel: 82-41-550-7661, Fax: 82-41-550-0039, E-mail:
[email protected] Copyright ⓒ 2018 Korean Association for Research, Procedures and Education on Trauma. All rights reserved. cc This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ ◯ licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited
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Trauma Image Proced 2018(1):25-27
used to tamponade and control hepatic hemorrhage and thereby
abbreviate
the
operation
(1).
A
planned
reoperation after the damage control surgery for hepatic injury has been reported to result in better survival rates and fewer infectious complications with perihepatic packing and appropriate antibiotics rather than with anatomical resection of the liver in an acute setting (2). Because this case was that of a penetrating injury with a diaphragm
rupture,
despite
stable
hemodynamics,
surgical management had to be primarily considered rather than angiographic intervention. As this patient showed grade V laceration according to the liver injury scale of American Association for the Surgery of Trauma, it was obvious that an initial anatomic resection could result in death, whereas effective perihepatic packing could lead to a definitive surgery with physiological stabilization even for major hepatic injury. Conflict of Interest Statement No potential conflict of interest relevant to this article was reported. Fig. 1. External photographs revealing a penetrating wound in the right lower chest with herniation of the omentum
Fig. 2. Abdominal computed tomography showing (A) the irregular margined low attenuation of the right hepatic lobe, herniation into the wide intercostal space (white arrow), and multiple rib fractures, as well as (B) a herniation of the large bowel (white arrow) via the diaphragm defect
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Dong Hun Kim. Hepatectomy After Damage Control Surgery
REFERENCES 1. Garrison JR, Richardson JD, Hilakos AS, Spain DA, Wilson MA, Miller FB, et al. Predicting the need to pack early for severe intra-abdominal hemorrhage. J Trauma. 1996;40(6):923-7; discussion 927-9. 2. Caruso DM, Battistella FD, Owings JT, Lee SL, Samaco RC. Perihepatic packing of major liver injuries: complications and mortality. Arch Surg. 1999;134(9):958-62; discussion 962-3.
Video Legends Video 1. A video recording of the damage control surgery with primary repair of the right diaphragm, perihepatic packing, and temporary abdominal closure Video 2. A video recording of the definitive surgery with right hemihepatectomy and definitive abdominal closure after the damage control surgery
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