[size=20px]Following a bicycle crash in which the handlebars struck him in the right side, a six year old boy immediately has right sided pain and shortness of breath. He is transported to the hospital by ambulance. The emergency medical technicians report that he had one episode of hypotension (blood pressure 60/34 mm Hg) during transport and received 1000 ml of lactated Ringer's solution. In the emergency department he is pale, moaning, and complains of severe abdominal pain. His vital signs are Temperature 36.4 C (97.5 F) Blood pressure 56/36 mm Hg Pulse rate 140/min Respiratory rate 46/min

At laparotomy there is a parenchymal disruption involving seventy-five percent of the right hepatic lobe. There is vigorous venous bleeding and 1000 ml of packed red blood cells are transfused. He is oozing from multiple sites. The most appropriate management is :

 

A. absorbable mesh patch of the liver

 

B. primary suture repair closure of the liver laceration

 

C. packing and closure

 

D. right hepatic lobectomy

 

E. placement of an intracaval stent[/size]

Edited November 30, 20205 yr by Admin

A

Think again my friend

Many surgeons usually use mesh wrapping for hepatic trauma. Mesh wrapping is to use absorbable synthetic mesh to pack the damaged area of the liver or the entire organ, to achieve hemostasis by compression. This method is suitable for extensive damage to the liver parenchyma or star-shaped liver laceration, which has vitality and is connected with hepatic pedicle.

The correct answer is C. Although more than eighty percent of blunt liver injuries in children can be managed nonoperatively, this child presented in uncompensated shock and prompt laparotomy was indicated. It can be very difficult to establish hemostasis and maintain hemodynamic stability intraoperatively in the face of acidosis, hypothermia, and coagulopathy. These factors have resulted in a trend towards "damage control" in severe intraabdominal injuries. The first step in this approach is an abbreviated laparotomy, packing, temporary closure of the abdomen, and possible embolization. The next phase is aggressive resuscitation in the intensive care unit, correction of the coagulopathy and hypothermia, volume resuscitation and reversal of the acidosis. The third stage is delayed operation with packing change or removal, definitive repair of injuries, and abdominal wall closure. This approach is remarkably unsuccessful if applied as an afterthought in moribund patients who have failed repeat attempts at hemostasis. It results in survival of a majority of patients if applied in a planned fashion before irreversible shock occurs. (IV. Trauma E. Abdominal)