Fraz Fahim, Sulemna Farooq.
Operative Management of Massive Hepatic Trauma.
Ann King Edward Med Uni Jan ;8(2):136-7.

Few injuries pose as formidable a challenge to the trauma surgeon as a major hepatic injury. When this combines with a juxtahepatic IVC injury it becomes one of the most life threatening injuries encountered in general surgery. This is a case report of a young male who presented to us in shock with a run over injury with ambiguous signs of peritonitis. Upon doing an exploratory laparotomy, he turned out to have major hepatic and splenic trauma with a lateral rent of juxtahepatic IVC. Hepatic segmentectomy, splenectomy and a repair of IVC were done. The patient survived with minor post op complications, and is now doing well and has resumed his routine daily activities.

Case Report: A young male of 15 years was rushed to the emergency department approximately one hour after being run over by a vehicle. On admission his Pulse was 110/min, B.P. was 95/65 mm Hg, R.R. was 21/min, Temp. was 37°C and had a GCS of 14/15. He complained of severe pain in the both upper quadrants. On examination he was in some pain and lying supine. He was pale and moderately tender in the upper abdomen, which was distended with absent bowel sounds. There was no bruising or wound on the abdomen. He was resuscitated with 1.5 liters of Ringer`s Lactate and his vitals stabilized. He was placed under observation. Serial monitoring revealed a rising pulse and a falling systolic blood pressure. A decision to explore the abdomen was taken. On exploratory celiotomy, about a liter of blood was evacuated from peritoneal cavity. He was found to have a spleen bleeding profusely from a grade three laceration; splenectomy was done. There was almost a complete transaction and devitalization of a part of liver roughly corresponding to areas 7 and 8 with a massive, expanding right-sided Zone 2 retroperitoneal hematoma. Resection of the devitalized areas was done with cautery dissection and ligation of individual vascular and biliary channels. As the area 8 was lifted off a rent in the juxtahepatic Inferior Vena Cava (IVC) which had been tamponaded previously started hemorrhaging furiously. Massive resuscitation with blood and colloids was immediately started. A side rent in the IVC at the point where it had just emerged from behind the liver was identified and successfully repaired over a Satinsky`s clamp with continuos Prolene 5/0. In all he received 7 pints of blood transfusion peroperatively. There was no other injury found. Drains were placed in the Morrison`s pouch and in the Splenic bed. Patient remained critical due to acute anemia and high grade swinging pyrexia since the first post op day. His Hb was built up to 11.3g/dl by multiple transfusions. His pyrexia settled on 7h post op day and the antibiotics were stopped 48hrs later. He initially had heavy drainage of bile from his subhepatic drain to the range of -700ml / 24 hrs but it decreased steadily over the next few days. This drain was taken out on 100th post op day. Subsequently an USG abdomen on 16th POD showed a collection of 150m1 in subhepatic area. Since the patient was asymptomatic, he was discharged on 16th POD. A subsequent USG on 29th POD showed a significant decrease in the size of the collection. The patient was well two months postoperatively and had resumed his full daily activities. He is on regular follow up.

USER COMMENTS

good save; but in retrohepatic caval injuries one should pack and run
Posted by: nahmed on Aug 2003

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