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Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report
Jun Soma1, Daisuke Ishii2, Hisayuki Miyagi1
1Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan.
Insights
Damage control (DC) surgery effectively treated a child with severe blunt hepatic injury and multiple organ damage. This approach, utilizing negative pressure therapy, rescued the patient without neurological deficits.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Surgical Critical Care
Background:
- Blunt hepatic injury leading to intra-abdominal hemorrhage is a significant cause of mortality in trauma patients.
- Damage control (DC) surgery is a critical intervention for unstable pediatric patients with abdominal trauma.
- The ABTHERA Open Abdomen Negative Pressure Therapy System was employed in a novel application for DC surgery.
Purpose of the Study:
- To report the successful use of damage control surgery with negative pressure therapy in a pediatric patient with severe blunt hepatic injury.
- To highlight the effectiveness of a staged, flexible approach in managing complex pediatric abdominal trauma.
- To present a case of successful rescue without neurological sequelae using advanced surgical techniques.
Main Methods:
- An 8-year-old boy with grade IV blunt hepatic injury, thyroid injury, and hemopneumothorax underwent exploratory laparotomy.
- Damage control surgery involved gauze packing for hemorrhage control and application of the ABTHERA Open Abdomen Negative Pressure Therapy System.
- Management included percutaneous and external drainage for a subsequent biliary fistula.
Main Results:
- The patient survived and showed no neurological sequelae following the damage control surgery and negative pressure therapy.
- A biliary fistula developed but was successfully managed with drainage, leading to patient recovery.
- The patient was discharged 102 days after the initial injury.
Conclusions:
- Damage control surgery is an effective strategy for pediatric patients with severe blunt hepatic injury, offering better hemodynamic reserve utilization compared to adults.
- Early application of DC surgery, before the development of the trauma triad of death, can improve outcomes in critically injured children.
- A multi-stage, flexible management approach is crucial for achieving favorable outcomes in pediatric trauma cases.
Background:
Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae.
Case Presentation:
An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury.
Conclusion:
The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.
