Tamponing in severe liver injuries (two clinical cases)

Yu. G. Shapkin; Шапкин Ю. Г.; Yu. V. Chalyk; Чалык Ю. В.; N. Yu. Stekolnikov; Стекольников Н. Ю.; A. E. Katalnikov; Катальников А. Е.; V. V. Ashevskiy; Ашевский В. В.

doi:10.17816/pmj414148-152

Tamponing in severe liver injuries (two clinical cases)

Authors: Shapkin Y.G.¹, Chalyk Y.V.¹, Stekolnikov N.Y.¹, Katalnikov A.E.¹, Ashevskiy V.V.¹
Affiliations:
1. Saratov State Medical University named after V. I. Razumovsky
Issue: Vol 41, No 4 (2024)
Pages: 148-152
Section: Clinical case
Submitted: 06.03.2024
Accepted: 26.08.2024
Published: 03.10.2024
URL: https://permmedjournal.ru/PMJ/article/view/628820
DOI: https://doi.org/10.17816/pmj414148-152
ID: 628820

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Abstract

Favorable outcomes of surgical treatment of two patients with blunt liver damage of IV degree according to E. Moore as part of polytrauma are presented. In conditions of unstable hemodynamics and extremely severe state of the patient, the authors used a method of liver damage tamponing with a single tampon material (cotton surgical sheet) as an initial hemostasis. The applied method of liver damage tamponing helps to achieve a stable initial hemostasis, it does not require a highly-qualified surgical team and can be used in second- and third-level trauma centers.

Keywords

Severe liver injuries, liver tamponing, liver tamponing with sheets, damage control surgery

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Introduction

The treatment of severe liver damage remains a significant challenge in trauma surgery, with high associated mortality rates [1; 2]. Liver damage often occurs as part of combined injuries and polytrauma and is frequently accompanied by traumatic shock, influencing the surgical approach within the framework of the Damage Control strategy. In such cases, regardless of the trauma center level, tamponing of grade III–IV liver ruptures (according to E.E. Moore, 1989) is the initial step in hemorrhage control [3–5]. Our experience with gauze tamponing for severe liver damage, using gauze stitched into a "tape," has demonstrated that this technique can serve as a definitive method of hemostasis for liver trauma. This approach eliminates the need for further hemostatic interventions or re-laparotomy for tampon removal [6]. Despite over a century of experience using tamponing for liver damage, efforts continue to optimize this technique. A resuscitative liver packing method has been proposed and widely implemented as an enhancement [7]. Based on the experience at the N.V. Sklifosovsky Institute, A.S. Ermolov et al. (2003) suggested filling the subphrenic space, which requires extensive mobilization of the liver, a challenging task when using gauze packs to achieve an adequate tamponading effect [8]. In such cases, D.V. Feliciano (2015) recommended placing packs of gauze between the liver and the abdominal cavity walls to achieve the necessary compression and mechanical hemostasis. The procedure is concluded by forming a laparostomy and partially closing the skin wound to maintain pressure. Efforts are being made to develop devices for controlled compression of the damaged liver [9].

Currently, tamponing remains an effective method for achieving hemostasis in liver trauma surgery [10]. Therefore, improving tamponing techniques and optimizing the timing for tampon removal are crucial objectives in emergency surgery.

The aim of this study is to present two clinical cases involving the treatment of severe liver injuries in patients with significant traumatic shock using a packing method with volumetric tamponing material.

Materials and methods

A retrospective analysis of two clinical cases of patients treated at the State Budgetary Healthcare Institution «Academician V.N. Koshelev City Clinical Hospital No. 6», Saratov, was carried out.

Clinical case 1

Patient K., an 18-year-old female, was admitted to the hospital following a road traffic accident. On admission, her condition was extremely severe due to traumatic shock. She was diagnosed with severe polytrauma, including a closed craniocerebral injury with brain concussion, chest contusion, heart contusion, closed abdominal injury, retroperitoneal hematoma, and right kidney contusion, with Grade 3 traumatic shock. Given the severity and nature of her injuries, an urgent laparotomy was performed, revealing 2000 ml of blood with clots in the abdominal cavity. Upon evacuation of the blood and clots, multiple stellate lacerations of the right lobe of the liver along the diaphragmatic surface were identified, classified as grade IV according to E. Moore, with ongoing hemorrhage. A retroperitoneal hematoma was found in the projection of the right kidney. Due to arterial hypotension (BP – 60 and 40 mm Hg), we performed a one-stage tight filling of the space between the liver and the abdominal cavity walls with a sterile surgical sheet («lump»), without preliminary mobilization of the right lobe, providing uniform compression of the liver wounds by the abdominal wall, diaphragm and the tamponing material itself. Laparostomy with skin reduction to maintain pressure was performed. Further revision of other injuries of the abdominal organs revealed none. The posterior leaf of the peritoneum above the hematoma was dissected, the right kidney was revised and no damage was found. The abdominal cavity was drained with two polyvinyl chloride tubes under the liver. In the postoperative period, the patient was in the intensive care unit, where she received anti-shock measures aimed at stabilizing hemodynamics, replenishing the circulating blood volume deficit, correcting coagulopathy, and symptomatic therapy (the second stage of the Damage control tactics). After her condition stabilized, one day later, the patient underwent removal of the tampon in the operating room, the hemostasis was stable. The liver wounds were sutured with U-shaped sutures with packing using a strand of the greater omentum. There was no recurrence of bleeding. The further postoperative period proceeded without complications.

Clinical case 2

Patient Z., a 37-year-old male, was admitted to the hospital following a road traffic accident. On admission, his condition was extremely severe due to traumatic shock. He was diagnosed with severe polytrauma, including a closed craniocerebral injury with brain concussion, closed abdominal injury, retroperitoneal hematoma, contusion of the right kidney, dislocated left hip, fracture of the upper third of the right tibia, and fracture of the third metatarsal bone on the right side, along with Grade 3 traumatic shock. Given the severity and nature of his injuries, an urgent laparotomy was performed, revealing 2000 ml of blood with clots in the abdominal cavity. After evacuation of the blood and clots, multiple stellate lacerations of the right lobe of the liver extending from the diaphragmatic surface to the visceral surface were identified, classified as grade IV according to E. Moore, with ongoing hemorrhage. Given the severe shock, we performed a one-stage tight filling of the space between the liver and the abdominal cavity walls with a sterile surgical sheet, without preliminary mobilization of the right lobe, providing uniform compression of the liver wounds by the abdominal wall, diaphragm and the tamponing material itself. The wounds on the visceral surface of the liver were tightly packed with another sheet, «lump». A drainage tube was placed at the site of operation. Further revision of other injuries of the abdominal organs revealed none. Laparostomy with skin reduction to maintain pressure was performed (Figure). In the postoperative period, the patient was in the intensive care unit, where measures were taken to stabilize hemodynamics, replenish the circulating blood volume deficit, correct coagulopathy, as well as symptomatic therapy. After his condition stabilized, one day later, the patient underwent removal of the tampon in the operating room – hemostasis was stable. The wounds were sutured with U-shaped sutures with packing using a strand of the greater omentum, and there was no recurrence of bleeding. The postoperative period proceeded stably.

Fig. Subhepatic packing with a surgical sheet. The view before removing the tampon