Staged laparotomies based on the damage control principle to treat hemodynamically unstable grade IV blunt hepatic injury in an eight-year-old girl

Abstract

Background: Severe blunt hepatic injury is a major cause of morbidity and mortality in pediatric patients. Damage control (DC) surgery has been reported to be useful in severely compromised children with hepatic injury. We applied such a technique in the treatment of a case of hemodynamically unstable grade IV blunt hepatic injury in an eight-year-old girl. This case is the first to use multimodal approaches including perihepatic packing, temporary closure of the abdominal wall with a plastic sheet, transarterial embolization (TAE), and planned delayed anatomical hepatic resection in a child.

Case presentation: An eight-year-old girl was run over by a motor vehicle and transferred to the emergency department of the local hospital. Her diagnoses were severe blunt hepatic injury (grade IV) with left femoral trochanteric fracture. No other organ injuries were observed. Because her hemodynamic state was stable under aggressive fluid resuscitation, she was transferred to our hospital for surgical management. On arrival at our institution about 4 h after the injury, her hemodynamic condition became unstable. Abdominal compartment syndrome also became apparent. Because her condition had deteriorated and the lethal triad of low BT, coagulopathy, and acidosis was observed, a DC treatment strategy was selected. First, emergent laparotomy was performed for gauze-packing hemostasis to control intractable bleeding from the liver bed, and the abdomen was temporarily closed with a plastic sheet with continuous negative pressure aspiration. Transarterial embolization of the posterior branch of the right hepatic artery was then carried out immediately after the operation. The lacerated right lobe of the liver was safely resected in a stable hemodynamic condition 2 days after the initial operation. Bleeding from the liver bed ceased without further need of hemostasis. She was transferred to the local hospital without any surgical complications on day 42 after admission. She had returned to her normal life by 3 months after the injury.

Conclusion: The DC strategy was found to be effective even in a pediatric patient with hemodynamically unstable severe blunt hepatic injury. The presence of the deadly triad (hypothermia, coagulopathy, and acidosis) and abdominal compartment syndrome was an indication for DC surgery.

Keywords: Blunt hepatic injury; Children; Damage control surgery; Delayed hepatic resection; Transarterial embolization.

Fig. 1

a, b Axial view of an enhanced abdominal computed tomography (CT) scan shows the presence of active extravasation (arrow), large devascularization of the right hepatic lobe, and hemoperitoneum

Fig. 2

The patient’s abdomen after damage control surgery. Venous hemostasis was achieved by direct surgical gauze packing, and then the abdomen was closed temporarily using a plastic sheet to cover it

Fig. 3

a Hepatic angiography immediately after perihepatic packing shows extravasation arising from a posterior branch (arrows) of the right hepatic artery. b Hepatic angiography after coil embolization shows the complete cessation of extravasation and a preserved patency of the anterior branch of the right hepatic artery

Fig. 4

a Operative view immediately after delayed hepatectomy. Extended right lateral sectionectomy was performed after 48 hours of perihepatic packing. b A surgical specimen of the delayed hepatectomy. The excised liver was completely necrotic macroscopically and deep liver laceration was observed (arrows)

Fig. 5

An axial view of an enhanced abdominal computed tomography (CT) scan on the 14th day after extended right lateral sectionectomy shows no evidence of an intra-abdominal abscess and biloma. Embolized coils (arrow) are also observed