MASSIVE RECURRENT HEMORRHAGE FROM HEPATIC WOUND IN A PATIENT WITH COMBINED STAB-CUT INJURY OF CHEST AND ABDOMEN

MASSIVE RECURRENT HEMORRHAGE FROM HEPATIC WOUND IN A PATIENT WITH COMBINED STAB-CUT INJURY OF CHEST AND ABDOMEN 

Panasyuk A.I., Grigoryev S.E., Kondratyev S.A., Grigoryev E.G. 

 Irkutsk Regional Clinical Hospital of Order of Honour, Irkutsk State Medical University,
Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia 

Stab injuries to the chest and the abdomen with associated injury to the heart and the liver are accompanied by high mortality, mainly as result of massive hemorrhage. Treatment results highly depend on chosen subsequence of surgical management and also on efficiency of hemostasis, especially in deep hepatic wounds. The discussion of the last problem has been continuing for many decades. Multiple variants of temporary and continuous hemostasis, but all of them do not provide appropriate arrest of bleeding in all cases [1-5].
Objective – to discuss the specific features of surgical treatment in a patient with stab wounds of the heart and liver.
The study was conducted in compliance with the ethical standards of Helsinki Declare and the order of Health Ministry of RF No.200n (1 April 2016) “About confirmation of the rules for clinical practice”. The patient gave his informed consent for publication of the clinical case.  

CLINICAL CASE

The patient M., age of 22, was admitted one hour after the injury on 2 November 2017 (the medical record No.33428). His condition was severe (RTS = 6.8) and determined by hemorrhagic shock. The consciousness level according to Glasgow Coma Scale was 13 (moderate obtundation). The skin and the lips were pale. The pulse was 100 per min. Systolic arterial pressure was 80 mm Hg. Respiratory rate was 30 per min. There was a stab wound (1.5 cm) with smooth borders on the anterior surface of the chest to the right in the 4th intercostal space parasternum, with moderate bleeding. There was no right-sided breathing during auscultation. Anterior chest percussion showed tympanitis. Cardiac tones were muffled. There was a wound (1.5 cm) with smooth borders and fixed blood clot in the right hypochondrium along the midclavicular line. The anterior abdominal wall participated in breathing. It was soft during palpation, painful in the right hypochondrium. Abdominal percussion showed obtundation in inclined regions to the right. Physical examination was conducted on the surgical table.
Considering the wound in the zone by I.I. Grekov, hypotonia, muffled heart sounds, absent respiratory cycles to the right, we suspected a heart wound and hemopneumothorax.
The anterior-lateral thoracotomy in the 5th intercostal space to the right (Grigoryev S.E.) was conducted. The lung was collapsed, with about 500 ml of hemorrhagic fluid with clots in pleural cavity. The blood was moving from the pericardium wound (1.5 cm). Pericardiotomy was anteriad from the diaphragmatic nerve. 200 ml of flowable blood and clots were evacuated from the pericardium. There was a wound of the right atrium (length of 1.5 cm), 0.5 cm above the atrioventricular fissure, penetrating to its cavity. P-shaped sutures with prolene 4/0 and teflon layings were applied. Hemostasis was distinct. The pericardium was sutured with rare sutures with counterpuncture. There was a wound of the right internal thoracic artery (the artery was ligatured). The sutures were applied to the wound of the segment 5. The pleural cavity was sanitated. Two drains were placed.
A wound in the right hypochondrium penetrated the abdominal cavity. Middle laparotomy was conducted. The abdominal cavity contained about 500 ml of blood. There was ongoing bleeding from the wound of the 6th hepatic segment (up to 1.5 cm). It was sutured with single sutures with vycril 3/0. There were not any other injuries. The drains were placed into the small pelvis and the subhepatic space. The abdominal cavity was sanitated.
The patient was transferred to the intensive care unit. The diagnosis was: “Associated injury. A stab chest wound to the right with penetration to the right pleural cavity. Wounds of right atrium, internal thoracic artery and 5th lung segment. Right-sided middle hemopneumothorax. A stab abdominal wound penetrating into the abdominal cavity. A wound of 6th segment of liver. Hemoperitoneum. Compensated hemorrhagic shock. Injury severity: ISS 34, RTS 6.8, TRISS 88.3 %”.
Intensive delivery of blood with clots through the drains from the abdominal cavity was noted 4 hours later. Relaparotomy (Panasyuk A.I.) was conducted. There were some blood clots (about 150 ml) in the abdominal cavity, mainly over and under the liver. Ongoing bleeding was from the sutured wound of the 6th liver segment. There was a detachment of Glisson’s capsule over 5 cm. Temporary hemostasis was with digital occlusion. The right lobe was mobilized after transection of round, crescent and right triangle ligaments. The ligatures were removed. The hepatic parenchyma contained a cavity of 50 cm3 with blood clots and ongoing bleeding.
Temporary hemostasis was conducted with Pringle’s maneuver – bleeding decreased. The parenchyma was dissected along the wound channel. The injured segmentary veins and bile duct of the 6th segment were clipped (Fig. 1).

Figure 1. The patient M., age of 22, liver parenchyma dissection along wound channel. Clipped bile duct of the segment VI

Arterial bleeding from the bottom of the hepatic wound restored after removal of Satinsky clamp from the hepatoduodenal ligament. The bleeding vessel could not be visualized. The formed cavity was packed. The own hepatic artery and its right branch were separated. Arterial bleeding did not appear after cross-clamping the right hepatic artery (Fig. 2).

Figure 2. The patient M., age of 22, the artery of liver segment V is on the supports

The artery of the 5th segment of the liver was separated. Bleeding did not appear after its cross-clamping. Visible ischemia of other segments of the right lobe was absent. The artery of the 5th segment was clipped. The surgery was completed with omentohepatography and application of decapsuled liver with sudzhisel. Additionally, a drain was placed under the diaphragm to the right. A sponge was placed near the liver (Fig. 3).

Figure 3. The patient M., age of 22, omentohepatorrhaphy

The treatment was continued in the intensive care unit. Anemia was corrected with transfusion of 600 ml of packed red blood cells.
The drains were removed from the pleural cavity after 18 hours. The control X-ray image showed the outspread lung. Sanitation fiberbronchoscopy was conducted. A moderate amount of sputum was found in the lumen of tracheobronchial tree. Mucosa was hyperemic. Saline was used for sanitation.
Control electro- and echocardiography did not find any abnormal changes. Pericardium cavity did not contain any fluid.
The abdominal drains were removed after 48 hours, the sponge – on the seventh day. The postsurgical course was without complications.
After removal of the sponge, the ultrasonic abdominal examination was conducted that did not find any free fluid. The hepatic segments 5-6 contained an unsmooth formation of 5 × 3 cm. The structure of the formation was mainly parenchymatous without fluid component.
Three-phase MSCT-angiography was conducted on the day 14: the liver with smooth contours, not enlarged, unsmooth structure – the segment 6 contained a hypodensive (10-19 HU) round formation of 77 × 44 mm (greater omentum).
The other parts of the hepatic parenchyma showed even accumulation of the contrast after intravenous intensification (82 HU). Gall bladder was reduced. The arterial phase: the branch of the 5th segment of the right hepatic artery was not contrasted. The abdominal aorta and its visceral branches showed even contrast, with smooth, clear contours and usual caliber. The portal, splenic and superior mesenteric veins showed even contrast without dilatation.
On the day 15, the patient was discharged. His condition was satisfactory, with normal biochemical and hematological values. 

CONCLUSION

1. Correct estimation of priority of causes of patient’s condition with associated injury to the chest and the abdomen, and identification of a life-threatening injury (heart injury) allowed correct identification of management.
2. Ongoing arterial bleeding from hepatic vessels is associated with inadequate hemostasis, formation of tense intrahepatic hematoma and its draining into the abdominal cavity through a sutured wound.
3. Adequate draining of subhepatic space and follow-up in the intensive care unit allowed timely diagnosis of bleeding.
4. Relaparotomy as result of appropriate revision of a wound channel identified the source of arterial bleeding, with use of maneuvers of temporary hemostasis.
5. Final hemostasis was achieved after ligation of the artery of the 5th segment of the liver with subsequent omentohepatography.

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